Network Rail says it is significantly reducing risks at railway level crossings. But the company remains tainted by allegations of a ‘cover-up’ over the deaths of two young people at a crossing in 2005.
Letting children skate
on thin ice
Level crossing safety after Elsenham
Researched and written by Paul Coleman
1: Saturday mourning: Two teenage friends set out to take a train from a railway station with a long history and a very unusual layout.
2: Network Rail and level crossings: Network Rail is responsible for the safety of Elsenham station’s footpath level crossing.
3: Happy and excited: The two girls buy tickets. Trains approach. But tragedy follows.
4: Grief and anger: Elsenham’s footpath crossing is a ‘bear trap’. Experts also say the crossing still poses great dangers to users.
5: Network Rail – the company: The girls’ families encounter Network Rail, the ‘hybrid’ organisation responsible for railway safety.
6: RSSB investigation: The Rail Safety and Standards Board publishes the findings of an investigation into the Elsenham fatalities.
7: RAIB investigation: Rail accident investigators publish their analysis of the Elsenham fatalities.
8: Inquest: A jury at a Coroner’s Inquest hears from witnesses and safety officials – but some evidence is not heard.
9: Grayrigg: Network Rail apologises for the Grayrigg derailment and fatality. Meanwhile, Network Rail settles civil actions over Elsenham.
10: Hudd and Hill: Anger flares as ‘whistleblown’ documents show Network Rail knew long ago Elsenham’s footpath crossing was dangerous.
11: Who knew? Who knew about Elsenham’s dangers before the fatalities occurred? Allegations of a ‘cover-up’ fly.
12: “Spinning plates”: Network Rail pleads guilty to health and safety charges over Elsenham. Network Rail closes level crosses across the UK.
13: Thin ice: Network Rail is fined over Elsenham as cover-up allegations linger. Another young person is killed in similar circumstances.
14: New safety measures: Network Rail seeks to reduce level crossing risks with a new team as new safety technology emerges.
15: Inquiry by MPs: MPs hold Network Rail officials to account by MPs for the company’s ongoing record on level crossing fatalities and safety.
16: Closing level crossings: Network Rail continues to close level crossings but the rail regulator remains unsatisfied.
17: A new era? – Does Network Rail’s debts and lack of public accountability continue to compromise level crossing safety?
18: A ‘sorry’ apology: MPs publish their level crossing safety report. Network Rail apologises for the way it has treated victims’ families.
19: An Elsenham legacy: The Elsenham fatalities bequeath both a legacy of injustice and of level crossing safety enhancement.
20. Postscript Elsenham – Personal reflections on how the death of two teenage friends changed not only a railway station but rail safety culture.
PART 1: SATURDAY MOURNING 1. Saturday, 3 December 2005. 2 Elsenham station (2005) 3. A rural station 4. Crossing the railway 5. Level crossings 6. Footpath crossings 7. Risk and personal responsibility 8. Footpath crossing gates 9. Sighting times, distances and curvature 10. Staggered platforms 11. Miniature Warning Lights 12. Yodel alarms 13. Crossing keeper 14. Signalling 15. Station buildings 16. Up line Platform 1 17. Down line Platform 2 18. Buying tickets 19. Level crossing sequence (2005)
1. Saturday, 3 December 2005
Rewind to 3 December 2005. It’s one of those relaxed Saturday mornings that older children enjoy, especially after a week of teachers, homework and school.
Intermittent cloud interrupts bright mid-morning sunshine but the cosy promise of Christmas looms brightly.
Two young friends, Olivia and Charlotte, cheerfully embark on a shopping trip to buy Christmas gifts in the famous English university town of Cambridge.
Earlier that week, Olivia and Charlotte have planned their Saturday morning adventure on their computers. The friends have messaged each other via MSN, the online instant messenger service.
Both Olivia and Charlotte attend Newport Free Grammar School. Olivia began her education at Little Hallingbury Church of England primary school. Charlotte started at Henham and Ugley, another Church of England primary.
Born on 28 November 1991, Olivia, aged 14, is slightly older than her friend Charlotte. Popularly known as ‘Liv’, Olivia loyally remains in contact with several friends from her junior school days at Little Hallingbury.
‘Liv’ charms everyone with her smile and cheerful greeting, say her family. She likes to joke but never maliciously – and often laughs at herself too. Olivia shows early signs of being a budding TV reporter. She also swam with dolphins in 2003.
For Charlotte, born on 10 March 1992, today represents a change to her normal Saturday morning routine. Every Saturday for the past six months, Charlotte, aged 13, has got up early to go and work with her father, Reg, for her Uncle Davy’s wholesale delicatessen business.
Charlotte, or ‘Charlie’, as family and friends affectionately call her, proves to be a diligent co-worker. By December 2005, Charlotte has earned and saved enough money to go Christmas shopping.
Charlie is ‘vivacious, beautiful and generous,’ say her family. Charlotte likes theme parks – and writing poetry. In 2004, Charlotte writes in a card for her father: ‘I love you Daddy more than an infinite number of giant buffalos charging.’
2. Elsenham station (2005)
It’s 10.30am. Olivia and Charlotte reach their local railway station at Elsenham on this dry and mild Saturday morning. On weekdays, Elsenham station bristles with determined commuters. On Saturday mornings, like today, the platforms breathe more easily.
The station serves the small yet growing village of Elsenham, set in rural undulating Essex countryside, 30 miles (53 kilometres) north of London and 20 miles (32km) south of Cambridge. The railway and station sits between the village’s main development of houses and streets to the west, and an expanse of mainly open, cultivated tree-lined fields to the east.
The station lies on the busy West Anglia Main Line, one of the UK’s main rail arteries, that serves London Liverpool Street – a major central London commuter terminus – and other stations including Audley End, Bishop’s Stortford and Cambridge. An eastward branch to the south of Elsenham carries air travellers to and from Stansted, one of London’s five international airports.
Two railway lines, an Up and a Down line, run between Elsenham station’s Platform 1 and 2. Both platforms can accommodate trains up to eight cars long.
Platform 1 serves Up line trains calling at Elsenham on their way south towards Stansted Airport and London Liverpool Street. Platform 2 allows passengers, like Charlotte and Olivia, to board trains heading north on the Down line towards Cambridge.
3. A rural station
Elsenham station originally opened in 1845. The station’s rare and unorthodox layout of platforms and buildings owes much to the quainter rural railways of a sleepier yesteryear – when slower trains operated less frequent services serving smaller Elsenham populations.
Elsenham typifies an English countryside station. Steam train services once passed through Elsenham. In April 1993, the station pays homage to its past by hosting a steam engine gala. Amateur film footage shows hundreds of local people flocking to the bunting bedecked station. They admire chuffing steam engines and chugging vintage cars and lorries in the station’s nearby car park. Children sit and ride a miniature Great Western steam engine in an adjacent field. A fairground organ pipes cheery tunes.
In the early 21st century, 25kV overhead wires, suspended over the tracks, supply electric power to multiple unit passenger trains via train pantographs. Some multiple unit passenger trains use diesel, as do hulking freight trains.
Electrification enables more frequent and faster trains to stop at Elsenham and others to pass through. Each weekday and Saturday between 0630 and 0830hrs, 19 train movements occur at Elsenham, according to the timetable operative to 10 December 2005. Twelve are Up trains, five of which stop and seven pass through on their way south to Stansted or London. Of the seven Down trains, four stop and three go through on their way north to Cambridge.
The maximum speed for multiple unit passenger trains on this two-track section is 70mph (113km/h).
Some 172,500 journeys are made from Elsenham station during 2005, according to ticket sale records. This represents a 25,000 fall in sales since 2003. Season tickets form about two thirds of sales.
The overall number of people travelling from Elsenham is falling but large numbers of school children and students, en route to and from schools and colleges in Newport, Cambridge, Stansted Mountfitchet and Bishop’s Stortford, frequently use the station.
They include Olivia, who is familiar with the station as she uses it weekdays on her way to school.
4. Crossing the railway
In 2005 passengers completing a return journey from Elsenham will walk across the railway lines at least once. Some may walk across more than once.
For instance, a Cambridge-bound passenger without a ticket, walking from the village in the west, needs to walk across the tracks to reach the ticket office on the Up platform. She buys a ticket and crosses back over the tracks to the Down platform to wait for her Cambridge train.
Similarly, passengers like Olivia and Charlotte must cross the tracks to buy a train ticket. The Up platform is the only platform offering ticket sales via a booking office and a ticket machine.
In another instance, a London-bound commuter already with a ticket parks his car at the station car park on the eastern side of the station. He approaches the Up line platform and walks across the railway tracks to purchase a newspaper from the small shop located on the Down platform. He then walks back across the tracks again to reach the Up platform to catch his London-bound train.
5. Level crossings
Rail entrepreneurs and engineers built the UK’s railways over many decades. Often they could not afford to build bridges or tunnels at every point the rails crossed a road. They created level crossings – where road vehicles, pedestrians and animals could cross over railway lines.
About 7,000 level crossings dot the UK railways at the start of the 21st Century. Most are private or footpath crossings. About one fifth are on public roads. Level crossings come in all shapes and sizes, ranging from simple walkways over single tracks in remote rural areas to crossings where users need to telephone a signaller to ask permission to cross.
Crossings operate in busy cities and towns. A small number are located at stations. An even smaller number are station footpath crossings for pedestrians and intending passengers.
Vehicles and pedestrians must use Elsenham station’s two level crossings to cross the railway line. Vehicles use the road level crossing. Pedestrians and intending passengers should only use Elsenham’s station footpath crossing.
In December 2005, the station still has no alternative way to cross the railway when approaching trains are signalled. No subway or footbridge is provided.
Old Mead Road to the east and Station Road to the west join at Elsenham station. Cars and lorries on Old Mead Road and Station Road trundle east-west over the tracks on the two-lane, two-way vehicular level crossing. The railway tracks are embedded in the road to allow vehicles to cross smoothly.
Pedestrians can use the road crossing but there is no pavement or barrier to separate them from cars, vans, lorries and buses. Pedestrians and intending passengers, like Olivia and Charlotte, tend to cross between Platforms 1 and 2 via the footpath crossing that lies parallel and adjacent to the road crossing.
6. Footpath crossings
The term ‘footpath crossing’ owes much to a bygone era when most people travelled ‘on foot’ or, if not, on horseback when they crossed the railway. Many UK footpath and bridleway crossings were installed when fewer trains carried far fewer people.
About 4,500 UK crossings feature a ‘public right of way’ for pedestrians. Many originated in the Victorian era. Most operate at remote and rural locations.
Just 97 are ‘station pedestrian footpath crossings’ – and Elsenham is one of just two such footpath crossings that combine non-locking pedestrian gates, Miniature Warning Lights and a single tone audible alarm.
An estimated 132,000 crossings are made at Elsenham station’s footpath crossing during 2004-05, with 60-90 per hour at peak times. Peak time train frequency at Elsenham is higher too, with nine trains per hour. The frequency of peak hour Up and Down line trains means they arrive grouped closely together.
This also means the road is closed to road vehicles for several minutes to allow clusters of closely timed trains to pass in each direction. For instance, on weekdays in 2005, between 0825hrs and 0835hrs, five train movements occur at Elsenham; two through Up trains, one through Down train, one stopping Up train and one stopping Down train.
7. Risk and personal responsibility
People are in no hurry to use the vast majority of footpath crossings, particularly when it is not safe to cross. But intending passengers are often in a hurry to use station footpath crossings to make sure they catch a train.
This urgency creates risk. Even so, all crossing users are expected to observe signs, instructions and warnings and take personal responsibility for crossing safely.
Risk at road level crossings, like the one at Elsenham, is tightly controlled in 2005. Full road barriers that interlock with signalling and a crossing keeper protect road traffic users.
Risk at footpath crossings, like the station footpath crossing at Elsenham, is loosely controlled in 2005. Warning lights and alarms protect pedestrians and intending passengers but pedestrian gates do not lock. Safe use of the crossing is entrusted to the personal responsibility of each user.
8. Footpath crossing gates
Stepping out onto the crossing to cross the tracks at Elsenham in 2005 is almost as easy as it must have been in 1845.
Two parallel white lines painted on the ground guide footpath crossing users over the railway.
The combined span of the road and footpath crossings across the railway is 14.4 metres (15.8 yards). An average person might take up to ten seconds to walk over the footpath crossing.
Elsenham’s footpath crossing has two pedestrian gates, one at either side of the railway. This pair of wooden, white-painted, wicket-style, pedestrian gates looks like a 19th Century remnant.
The station footpath crossing gates never lock.
Installed at some time after 1967, both the Up and Down side gates feature no locks, latches or even handles. Official railway industry standards and guidance, reissued in 1996, says: ‘All wicket gates should be easy to open from either side and be self closing. Latches which might prevent the gate being opened quickly should not be used.’
Users simply open a gate by pulling it against a spring away from the track. They can then cross the railway.
They can leave the crossing on the other side by pushing against the second wicket gate that again springs open away from the track.
Olivia and Charlotte will have to open the gates to cross the railway tracks twice. Firstly, to buy train tickets from the booking office on the Up platform, and secondly, to cross back over the tracks to catch their Cambridge-bound train from the Down platform.
9. Sighting times, distances and curvature
The course of the West Anglia Main Line bulges north of Elsenham as it runs between Old Mead Road, a river and the M11 motorway. Hence, the Main Line curves through Elsenham station.
This curvature causes a serious safety risk at Elsenham’s footpath level crossing. Pedestrians standing at the footpath crossing gate near Platform 1 experience a significantly restricted view of trains approaching on the Up line.
The officially measured sighting time elapsed between a footpath crossing user, standing at the Up side wicket gate, first seeing a fast train on the Up line and that train actually reaching the crossing is very short – about only three seconds if the train travels at 70mph.
The sighting distance is 93 metres (102 yards).
The visual warning time of three seconds from the Up platform of approaching trains travelling at 70mph is therefore far less than the time taken to cross from the Up platform to the Down side (up to ten seconds).
Furthermore, a large concrete post, supporting the eastern vehicular crossing gate, can also block that three-second view and further diminish the sighting time and distance.
This is the Up line position from which Olivia and Charlotte will have to cross the tracks to reach the Down platform opposite.
10. Staggered platforms
In 2005, Olivia and Charlotte also step towards other lurking unorthodoxies. The road and footpath crossings span the tracks at skewed angles. Users must look over their right shoulders to check and see if a train approaches on the track nearest to them.
Unlike most stations, Elsenham’s platforms are also staggered diagonally opposite each other along the curve.
The road and footpath level crossings sit at the centre of the station, between the north end of the Up platform and the south end of the Down platform.
Passengers who purchase a ticket on the Up platform must walk down a short ramp to use the footpath crossing. On reaching the Down side they then have to cross the road and walk several metres up another ramp to get to the southern end of the Down platform.
11. Miniature Warning Lights
Barriers (automated or manually operated), warning lights, audible alarms, recorded audible messages, and instruction signage ‘protect’ many level crossings in the UK.
But, in 2005, Elsenham is one of only fourteen station footpath crossings in the UK with Miniature Warning Lights (MWLs) and signage instructions.
Elsenham’s MWLs were installed in 1984, partly due to the curvature of the tracks and the shortened sighting times and distances, particularly of the Up line from the Up platform.
The warning lights and their timings conformed to Department of Transport requirements, as set out in Railway Construction and Operation Requirements documents issued at the time of installation by Her Majesty’s Railway Inspectorate, the body chiefly responsible for rail safety at that time.
12. Yodel alarms
An audible yodel alarm also ‘protects’ Elsenham footpath crossing. The single tone alarm works in tandem with the MWLs.
Illuminated green MWLs mean it is safe to cross the railway. Red lights mean it is unsafe to cross, as a train is making its final approach to pass over the crossing.
Footpath crossing users must observe the colour showing on the MWLs. The green light is extinguished and a red light illuminated – and the yodel alarm sounds – a minimum of 20 seconds before the train arrives.
The red lights will continue to show and single tone yodel to sound if a second train is due within a minimum of 20 seconds. The lights continue to show and alarm sounds until all trains clear the crossing.
But the warning lights and single tone yodel alarm do not enable footpath crossing users to distinguish between the approach of a first train and then a second train – or warn of the simultaneous approaches of Up and Down trains.
Therefore, Elsenham station footpath crossing relies entirely on users observing the lights and acting in accordance with the yodel alarm warning and fixed signage instructions: ‘Cross only when green light shows’ and ‘Cross quickly’.
The signage also gives no advice to users about the risk of a second train coming. No verbal recorded warnings are broadcast either.
Identical wicket gates, warning lights and yodel alarm are situated on both sides of the crossing.
13. Crossing keeper
The crossing keeper is based in an Up side cabin close to both the footpath and road level crossings. The purpose of the crossing keeper’s job is to ‘operate the level crossing equipment to the highest standards of safety and performance’. However, this relates specifically to the road crossing.
There is no specific mention in the job description of the crossing keeper bearing any responsibility for the footpath crossing passengers and for members of the public who use it.
Yet, in many instances, Elsenham crossing keepers warn people when they use the footpath crossing when the MWLs show red. Some keepers even try to deter people from using the footpath crossing by warning them about the £1,000 trespass fine they could incur.
The on-duty road crossing keeper controls road traffic before a train arrives. A rota of keepers controls Elsenham. Each keeper normally works an eight-hour shift: 0600-1400hrs, 1400-2200hrs and 2200-0600hrs. Two occasionally work 12-hour shifts.
In 2005, Cambridge Power Signal Box controls the signalling between Cambridge and Stansted, the track that includes Elsenham. The signals are Track Circuit Block; a system that detects trains within a section of signalled track and so helps to keep trains a safe distance apart.
The railway line is divided into blocks. Each block is protected by a signal at its entrance. Train drivers respond accordingly to a stop or go indication.
This signalling interlocks with the full barrier road level crossing at Elsenham station. A signal is only cleared for a train to actually begin its approach to the station when the level crossing keeper locks the road crossing gates.
Signalling is not interlocked with the station footpath crossing gates, which are always unlocked.
A data recorder, fitted to the signalling equipment, records the timing and operation of the relays controlling the crossing MWLs, yodel alarms and the interlocking of the road crossing gates with the signalling.
15. Station buildings
Elsenham station features five small buildings. Three sit on the side of the Up line.
A grey-blue weather-boarded cabin with a flat covered gable roof, sits closest to the parallel road and footpath level crossings. This cabin houses the road crossing control panel, operated by the station’s level crossing keeper.
As mentioned, the level crossing controller operates and supervises the road crossing – but not the adjacent and parallel station footpath crossing.
16. Up line Platform 1
A short ramp leads up to Platform 1. A larger brick-built building sits next to the crossing keeper’s cabin, just a few metres from both level crossings. This building looks like a low two-storey house, with a tiled gable roof, chimney and a small side garden. It houses the ticket booking office and a larger office for the ticket clerk.
As mentioned earlier, the booking office, train ticket machines and ‘permit to travel’ machines are located only on the Up platform.
Further along Platform 1 stands another weather-boarded single storey building but with sash windows and a tiled, gable roof and central chimney. This houses the station’s waiting room. A timber canopy with an ornamental fascia, supported by cast iron columns with arched braces, provides passengers with a small amount of shelter on the long and largely exposed platform.
Track and train technology may have changed over the decades but Elsenham’s waiting room building looks like a mid-19th Century remnant. In February 1980, it attains Grade II-listed status as a building of ‘special architectural and historical interest’.
Open fields lie behind these buildings on Platform 1.
17. Down line Platform 2
The foot of the Down platform – Platform 2 – features a small shop selling newspapers, sandwiches, sweets, tea and coffee – but not train tickets. A small waiting room and a covered area sit further along the platform.
Importantly, Platform 2 has no ticket or ‘permit to travel’ machines.
Elsenham village housing lies beyond Platform 2.
18. Buying tickets
The booking office on the Up platform (Platform 1) opens Monday to Saturday, 0600-1330 hours. Passengers open a door and walk inside a small booking hall. A booking clerk sells tickets through a small window. The clerk cannot see the platforms from this position.
Two automatic ticket-issuing machines stand outside the booking office on the Up platform. The Avantix machines should operate at all times to dispense tickets to ten destinations. Passengers pay using chip and pin cards or with notes and coins.
But, according to reports, heavily used Avantix ticket machines prove unreliable.
Apparently, the Avantix machine at Elsenham is ‘out of action’ on 3 December 2005 when Olivia and Charlotte arrive at the station. Only the clerk in the ticket office can sell tickets on this particular Saturday morning.
A ‘permit to travel’ machine stands next to the Avantix machine. Users pay between 10p and £1 to buy a timed and dated token. This represents a promise to pay the right fare on the train or at the destination station.
The absence of any ticket sales points or machines on the Down platform means passengers, who walk to the station from the village, must cross the railway twice if they need to buy a ticket for a Cambridge-bound train. Passengers who join a train without a ticket risk being charged a £20 penalty fare on top of the actual ticket fare.
19. Level crossing sequence (2005)
In 2005, the level crossing at Elsenham operates according to the following sequence.
A train approaching Elsenham station on either the Up or Down lines trips a track circuit. A bell rings at the station. Two bells can ring; one for a train on the Up line, the other for a Down line train.
On hearing the bell(s), the crossing keeper walks to the road crossing. He manually closes the road crossing gates to road vehicles in order to open the railway to trains. When closed to road traffic, the barrier gates span the full width of the road on both sides of the crossing.
The keeper locks the road crossing gates and then removes one key from each gate. The gates cannot be reopened without these keys.
The keeper goes back inside his cabin with both road gate keys. He inserts each key into a control panel and rotates them to a locked position.
This stops the bell(s) ringing.
It interlocks the road crossing gates with the signals.
This interlocking means the signaller at the Cambridge Power Signal Box is now in control of the railway, including the vehicular road crossing. The signaller can now set the route for the approaching train by changing the signals to a proceed aspect. Trains can now proceed towards Elsenham station.
However, the keeper is not formally responsible for the footpath crossing. After he closes and locks the road gates, pedestrians and passengers can continue to open both footpath crossing gates and cross the railway before trains arrive – without supervision by the crossing keeper.
Generally, crossing keepers can take action if they believe individuals are exposing themselves to danger – a Rule Book duty for all railway staff. However, crossing keepers’ specific duties do not include ‘policing’ usage of footpath crossings.
A period of two to three minutes now passes, depending on the speed of the approaching train(s).
The leading wheelset of an approaching Up train then ‘strikes in’ at another track circuit 646 metres (707 yards) from the Elsenham crossing. An approaching Down train ‘strikes in’ similarly at 715m (782 yds).
This ‘strike in’ operates relays that extinguish the green miniature warning lights at the footpath crossing and illuminate the red warning MWLs. This ‘strike in’ also activates the yodel warning alarm.
Even so, pedestrians and intending passengers can still open the station footpath crossing wicket gates and cross the railway from either side.
A non-stopping Up train travelling at 70mph (113km/h) can reach the crossing from the ‘strike in’ point in 20.6 seconds. A Down train takes 22.8 seconds. Trains at lesser speeds sometimes take up to one minute to reach and pass over the crossing after a ‘strike in’. These elapsed times are in line with railways safety standards of this period.
But the time between the activation of the warning lights and alarm and the arrival of an approaching train at the crossing is not stated at the crossing on any signage.
The trailing wheelset of a train clears the track circuits immediately after the crossing. This extinguishes the red MWL. A green light is restored. The single tone yodel alarm stops – but continues if a second train is still approaching on the opposite line.
Even if another train approaches, pedestrians and intending passengers can still open the station footpath crossing wicket gates and cross the tracks. Again, this is simply because the gates do not lock.
The Cambridge signaller allows the level crossing keeper to resume control of the crossing when all trains clear the track circuit section. This permits the crossing keeper to remove the crossing gate keys from the control panel in his cabin.
The keeper takes out the keys and reemerges from his cabin. He uses the keys to unlock the road crossing gates and reopen the crossing to road vehicles.
Throughout this entire sequence, station footpath crossing users can simply swing open the unlocked white wicket gates. They can use the footpath crossing even whilst red warning lights illuminate and the yodel alarm sounds – and even when trains are seconds away from reaching the station.
PART 2: Network Rail and level crossings 1. Network Rail and Elsenham 2. Risk Management 3. Risk reduction 4. Law and ALARP 5. Risk assessments 6. Safety responsibility 7. Rail safety campaigns 8. Safety mandate 9. April 2005 risk assessment
Network Rail and level crossings
1. Network Rail and Elsenham
Charlotte and Olivia are about to use a station footpath crossing owned and operated by Network Rail, the private company that owns and operates most of the UK’s railway infrastructure. In 2005, the company is responsible for the installation, inspection, maintenance and renewal of over 7,000 level crossings in the United Kingdom.
Network Rail says ‘Britain’s rail network is a marvel of engineering’. Train travel is ‘fast, quick, efficient, reliable and environmentally friendly’.
‘Cutting edge technology’, backed by ‘exacting safety standards’ enables Network Rail to manage the UK’s rail infrastructure. ‘Rail is the safest form of transport,’ says Network Rail. ‘And we’re continually trying to make it safer.’
However, when Olivia and Charlotte walk onto Elsenham’s two platforms, enter the booking office and board a train, they are using property and equipment leased by a train operating company (TOC). Network Rail owns Elsenham station – but leases it to a private train operator, ‘one’ Railway, itself owned by the National Express Group.
As a train service franchise holder, ‘one’ Railway is responsible for the station’s commercial activities, such as selling tickets. The franchise holder also maintains and upkeeps the passenger information systems, platforms and buildings, as required by the station lease agreement.
But, in July 2004, Network Rail’s Anglia route director Jon Wiseman announces stations like Elsenham will receive new customer information systems, along with improved waiting rooms, toilets and CCTV. “Network Rail is committed to providing safe, reliable and efficient railway infrastructure,” says Wiseman. “Comfortable stations with modern facilities are an important part of our continued programme to rebuild the railway.”
Network Rail is responsible for the signalling system that interlocks with the road crossing. The company is also responsible for the MWLs, wicket gates, footpath walking surface and their maintenance.
Although Network Rail owns and operates Elsenham road level – and owns but does not operate the station footpath crossing – the company is not responsible for the users of both crossings. Users of the footpath crossing bear exactly the same personal responsibility as pedestrians crossing at a traffic light controlled pedestrian road crossing. Passengers become responsible for their own safety as soon they step off the bottom of the platform ramp to cross the railway.
However, Network Rail is responsible for assessing and managing risks posed by station footpath crossings, like Elsenham.
2. Risk management
In 2005, Network Rail has no specialist managers dedicated to assessing and managing risk at level crossings. Managers include level crossing management amongst their other rail infrastructure responsibilities.
Nine Network Rail staff, each responsible for a UK region, liaise with British Transport Police (BTP) and Train Operating Companies (TOCs) to inform young people about the risk of ‘misbehavior, trespass and vandalism’ on the railways. They visit schools, youth clubs and young offenders groups.
Personal responsibility for observing signs and warnings and for crossing safely is emphasised. Audiences for safety presentations are identified on the basis of information from BTP officers, train drivers and reports logged on the UK railway’s national incident database, the Safety Management Information System (SMIS).
BTP officers reportedly visit Olivia and Charlotte’s school at Newport, just north of Elsenham, earlier in 2005.
3. Risk reduction
A Network Rail area general manager chairs an Anglia level crossing risk reduction and mitigation group (LXRAM). This brings together representatives of TOCs, signalling engineers, maintenance engineers and BTP officers. They identify crossings where problems arise and solutions are required.
The Anglia area of Network Rail includes some 100 level crossings. The LXRAM group reviews ten per cent at any one time. Reviews consider risk assessment results, incident occurrences, incident history, and public comments and complaints.
They also review safety related incidents recorded on SMIS. LXRAM reviews a level crossing risk assessment after SMIS records three ‘near misses’, and/or after a fixed period.
In December 2005, Elsenham is included in a list of crossings for review. SMIS shows three ‘near misses’, occurring in March 2004, July 2005 and November 2005. These ought to trigger a LXRAM review but it is said no information suggests the need for an urgent review.
Typical LXRAM remedies might include installing CCTV and a BTP presence to monitor and deter ‘misuse’ of a crossing.
Tailored safety measures for specific crossing are considered. For instance, the Rail Safety & Standards Board – the UK’s rail safety research agency – quotes an example arising at some point in 2005-06, where a pair of wicket gates is ‘currently locked out of use because of misuse. An evaluation of fitting the gates with locks was under consideration’.
The specific level crossing is not named.
4. Law and ALARP
The law, as it stands in December 2005, leaves footpath level crossing users, like Olivia and Charlotte, with some formal legal protection.
Level crossings law evolved spasmodically as the UK rail system grew rapidly over many decades. Accidents often compelled reviews of level crossing law.
But potential law changes were hampered by an official view that personal responsibility must lead the way. For instance, after the Hixon level crossing accident in January 1968, a public inquiry quoted and accepted a statement from a 1957 report that stated ‘…the principle must be recognised that it is the responsibility of the individual to protect himself from the hazards of the railway in the same way as from the hazards of the road’.
The Hixon tragedy killed eleven people on-board a 12-coach Manchester-Euston express train after it collided at 75mph with a heavy road transporter carrying a 120-ton transformer across an automatic level crossing. Forty-four other people were injured, six seriously.
Later, in 1983, Members of Parliament on a House of Commons committee reported on ‘pedestrian safety at public road level crossings’. They recommended changes to visual and audible warnings and to pedestrian access layout. Again, the principle of personal individual responsibility dominated their deliberations.
The Health and Safety at Work etc. Act 1974 applies to Network Rail. Since October 2002, Network Rail must comply with these provisions. Section 3 imposes an obligation on Network Rail to take reasonably practicable measures to ensure level crossing users are not exposed to risks to their health and safety.
This means Network Rail must assess the risks of a level crossing to all users, including people crossing and train passengers. Network Rail must put in place suitable safety measures to manage these risks down to a level that is ‘As Low As Reasonably Practicable’.
In 2005, under the Railways (Safety Case) Regulations 2000, Network Rail must also get Her Majesty’s Railway Inspectorate approval for any changes to a level crossing’s design or operation. In 2005, HMRI, established in 1840, still oversees safety on Britain’s railways through special documents. A safety case document records the safety management systems in place at each crossing – including risk assessments and measures to control risk to ‘As Low As Reasonably Practicable’ (ALARP).
Another set of documents governing level crossing safety emerges in 1996. The Railway Safety Principles and Guidance (RSPG) documents, published by the Health and Safety Executive, applies only to level crossings installed or modified after 1996, when RSPG is published. RSPG gives limited guidance on managing specific risks to crossing users, like Olivia and Charlotte, inherent at station footpath crossings, like Elsenham.
Paragraph 22 of the RSPG states ‘the choice of level crossings should avoid causing unnecessary delays to road users’. Elsenham station footpath crossing apparently met the following requirements:
- Trains passing over the crossing should not exceed 160km/h (100mph).
- Should not inhibit rail traffic frequency
- Span no more than two lines
- Possess warning times greater than the time it takes to cross
- Where MWLs are provided, the warning time should be greater, by not less than five seconds, than the time it takes to cross.
Network Rail must also ensure that the condition of gates or stiles at level crossings is consistent with The Railway Clauses Consolidation Act of 1845.
Until 2002, this patchy and often outdated legal framework is all that legally protects users from the risks of level crossings – especially, at station footpath crossings like Elsenham.
5. Risk assessments
The rail industry begins to modify its risk assessment approach in October 2002. The anodyne-sounding Railway Group Standard GI/RT/7011 – Provision, Risk Assessment and Review of Level Crossings – mandates risk assessments be carried out on all level crossings.
By late 2003, a February 2004 target for station footpath crossings is clearly unattainable. Network Rail focuses on risk assessments for road crossings, which according to accident figures, pose greater risks to rail passengers. Completion of risk assessments on station footpath crossings, like Elsenham, is delayed until October 2005.
In March 2005, Network Rail revises its Operation Manual so trained level crossing risk managers can begin semi-quantitative risk assessments of station footpath crossings. Risk scores are allocated to unauthorised use, number of users, train numbers, non-stop train numbers, train speeds, lines crossed, warning times, weather conditions, track cant, other local factors – and the ‘probability of anyone stepping out from behind a train into the path of another’.
Scores are totalled up to a maximum of ‘86’. If a level crossing scores more than ‘55’, steps should be taken to reduce risks. If it scores between ‘35’ and ‘55’, risk reduction measures should be considered. Less than ‘35’, no action is required, apart from a periodic review to see if any circumstances have changed.
Assessment Sheets clearly state this scoring system.
But this entire method is a ‘stop-gap’. Network Rail and other rail industry bodies are developing a computer-based model to estimate the risk of death each year at every crossing. A form of this model has existed since 1995 for road level crossings – and the aim is to deploy this All Level Crossing Risk Model to assess risks at station footpath crossings, like Elsenham, by the end of 2006.
6. Safety responsibility
Network Rail, Train Operating Companies and highway authorities share responsibility for maximising level crossing safety.
By December 2005, a National Level Crossing Safety Group aims to improve the behaviour of crossing users. A steering body consists of Network Rail, the Rail Safety Standards Board, Association of Train Operating Companies, British Transport Police, Health & Safety Executive, County Surveyors’ Society and the Department for Transport. A working group adds the civil police and the Driving Standards Agency.
7. Rail safety campaign
In the Spring of 2005, Network Rail also cranks up its rail safety campaign, ‘No Messin’!’ Press releases are headlined: ‘Kids need to wrestle with their consciences’.
DJ Spoony of BBC Radio 1 launches the campaign, saying: “All kids want to have fun, but the railway isn’t a safe place to play…I’m more than happy to support a campaign that keeps young people safe and out of danger.”
Iain Coucher, then Network Rail’s deputy chief executive, adds: “Last year 34 people died on railway tracks…Each one represents a tragic story of ignoring all the warnings that the railway is not place to hang around, use as a short-cut or play on.”
8. Safety mandate
Level crossings are deemed to constitute the greatest risk to railway safety, with collisions at level crossings between vehicles and trains as the most feared potential catastrophe.
A fatally catastrophic collision underpins this fear in November 2004. A passenger train collides with a car stopped on the Ufton Nervet road crossing.
In 2005, a clear immediate priority for Network Rail is to restore public confidence in the safety of the UK’s railways. A cluster of catastrophic train crashes has shattered public confidence:
- Ufton Nervet (seven killed, 71 injured, November 2004)
- Potters Bar (seven killed, 76 injured, May 2002)
- Great Heck or Selby (10 killed, 82 injured, February 2001)
- Hatfield (four fatalities, 70 injured, October 2000)
- Ladbroke Grove (31 killed, 425 injured, October 1999)
- Southall (seven fatalities, 100 injured, September 1997).
A vehicle on the tracks causes Great Heck. Trains failing to stop at red lights are the immediate causes of Ladbroke Grove and Southall.
Potters Bar and Hatfield are unequivocally caused by fragmented, excessively complex, and dysfunctional relationships involved in track maintenance. These ‘interface’ relationships are a legacy of the privatisation of Britain’s railways in 1996-97, and of Railtrack, the wholly private, profit-seeking company that took over responsibility from British Rail for railway infrastructure in April 1994.
Hatfield is often described as a ‘watershed moment’ for the privatised rail industry. Four people are killed in a buffet car that crashes into a lineside mast. The roof is torn off and the carriage side gashed.
Network Rail replaced Railtrack as rail infrastructure owner and operator in October 2002. Of those rail disasters, only Ufton Nervet occurs in the new Network Rail era – and a November 2007 inquest returns a verdict that the Ufton Nervet crash was tragically caused by the car driver’s suicide.
Reacting to British public pressure over Railtrack’s failures in relation to making the railways efficient, the government in 2002 mandates Network Rail to ‘improve railway safety, reliability and efficiency’.
The potential threat posed by cars to trains at level crossings is deemed more significant than the threat of trains to pedestrians at level crossings. But the number of pedestrians killed at all types of level crossings exceeds that of road vehicle occupants and train passengers.
Between 1994-2005, 122 people have been accidentally killed at level crossings of all types.
Pedestrian fatalities number 84, road vehicle occupants 32, and six are on board train passengers.
Suicides and suspected suicides are not included.
Three of the 84 fatalities occur at footpath crossings with Miniature Warning Lights.
The figures also suggest older people – and not younger people –are at greater risk at such crossings.
9. April 2005 risk assessment
Network Rail staff carry out an April 2005 risk assessment at Elsenham station footpath crossing.
They score the crossing with a risk total of ‘28’ – meaning a level of estimated risk requiring no safety improvements.
PART 3: Happy and excited 1. Approaching trains 2. ‘Strike in’ 3. Emergency brake 4. Aftermath 5. Trauma 6. Fatalities 7. Heartbroken 8. Charlotte 9. Olivia
Happy and excited
1. Approaching trains
It’s now just after 10.30 on Saturday morning, 3 December 2005.
Local resident Alison Dinsdale drives to Elsenham and drops her son at the station. Dinsdale sees him cross to the Down platform.
At this time, Olivia and Charlotte are making their way along the Up platform.
The girls go inside the booking office. Booking clerk Kim Wilmott is helping a passenger to renew a season ticket. According to Wilmott, Olivia and Charlotte are ‘happy and excited’ and want to catch the 10.41 train to Cambridge. The passenger renewing the season ticket is not in a hurry and stands aside to let the girls buy their tickets.
Charlotte and Olivia consider whether to buy tickets to travel to Cambridge and then return to Bishop’s Stortford, a station two stops south of Elsenham. The clerk repeats this request.
Olivia and Charlotte confer again. The girls opt for Elsenham-Cambridge-Elsenham return tickets. Wilmott repeats this second request. The girls agree. The clerk prints their tickets.
Charlotte and Olivia then discuss payment. One of the girls decides to pay for both tickets. Wilmott hands the tickets to the girls, who then talk to each other about sorting out the money.
The booking office system records the sales of two half-price return tickets at 1039 hours.
About five minutes earlier – at 1035hrs – the bell had sounded to notify the road crossing keeper of the train’s approach. The keeper begins to close the vehicular crossing gates and interlock them with the signals.
The girls’ intended northbound Down line train is a Class 317 Electric Multiple Unit consisting of four cars, with a total length of 81 metres (88.6 yards).
Craig Swanick, a driver instructor, responsible for the train, supervises trainee driver John Rossiter-Summers. The train has an On Train Data Recorder. This Cambridge service is running on time.
A minute earlier – at 1034 – a second oncoming train, travelling south on the Up line leaves Audley End station, six miles north of Elsenham.
Geoffrey Waters drives the Class 158 Super Sprinter train.
The train is a two-car Diesel Multiple Unit – the lead unit numbered 158856 – with a total length of 44 metres. The unit also has an OTDR.
Central Trains, a National Express subsidiary, operate the train service, the 0724 hours from Birmingham New Street to Stansted Airport.
This service is running at least two minutes late.
Olivia and Charlotte are still in the booking office on the Up platform as these two trains start to approach Elsenham. The girls will need to cross back over the tracks if they want to catch the 1041 Cambridge-bound Down line train.
By 1037, the keeper has closed and locked the road crossing gates to traffic and thereby opened the railway to the approaching train. Alison Dinsdale in her car is now one of the motorists waiting behind the closed road gates.
The keeper removes the two keys from the road gate mechanism. He returns to his cabin and places the keys into the control panel. This clears the signals to allow the Cambridge-bound train to call at Elsenham – and the Stansted-bound fast train to pass through.
At this time, as always, the pedestrian wicket gates are unlocked. Pedestrians and intending passengers can still use the footpath crossing, even though the road gates are locked and the railway opened to trains.
Signalling detects the final approach of the Cambridge-bound train. At 10.39 and 24 seconds, the Cambridge train ‘strikes in’ 715m (782 yds) from the station.
This activates treadles on either side of the crossing. These activate the single tone yodel alarm, extinguish the green lights and illuminate the red warning lights just two-tenths of a second after the ‘strike in’.
But there is no additional distinctive indication to warn footpath crossing users of the approach of the second train, the Stansted service. No signs or voice messages warn of the possible approach of a second and non-stopping train.
Neither do any signs state only 20 seconds could elapse between the activation of the warning lights and alarm and the arrival of an approaching train.
2. ‘Strike in’
The yodel alarm can now be heard. One of the girls asks the clerk if the alarm is for their Cambridge train. The clerk advises Olivia and Charlotte to check with the level crossing keeper. Wilmott hears one of the girls say: “I hope we don’t miss this train.”
The yodel alarm heard by the girls is for their Cambridge train, the 0950 hours London Liverpool Street to Cambridge service.
Charlotte and Olivia leave the booking office, go down the short ramp and reach the crossing gate at the north end of the Up platform.
10:39:51. Waters sounds the express train’s horn at the whistle board just north of Elsenham. The horn sounds almost at the same time as his train also ‘strikes in’.
The second train’s ‘strike in’ would have activated the warning lights and alarm at the footpath station crossing – but only if Waters’ express train had been the only approaching train. The Cambridge-bound train has already ‘struck in’ – and activated the lights and alarm 28.4 seconds earlier.
Even at this point, with both trains less than 30 seconds away from the station, pedestrians and intending passengers can still open the footpath crossing wicket gates and try to cross the railway.
Trainee driver John Rossiter-Summers hears the horn of the express about 400 yards ahead of him on the southbound track but the express train is still out of sight beyond the curve.
At this time, Waters in the express train cannot not see Elsenham station – and crossing users on the Up platform side are still unable to see the train and are possibly unaware of its approach if they have not heard its horn.
Rossiter-Summers slows his Cambridge train to about 30mph (48km/h) as it nears the crossing. The front end of the Cambridge train arrives at the crossing – 38.2 seconds after its ‘strike-in’. It will take 12.1 seconds for his train to clear the crossing.
Rossiter-Summers sees the girls standing at the non-locking pedestrian gate. One of the girls has her hand on the gate and opens it.
The other girl is seen running the short distance from the booking office to the gate. She is behind her friend when the front of the Cambridge train actually passes over the crossing.
“I made eye contact and shook my head, and mouthed, ‘I’ll wait’,” says Rossiter-Summers.
Witnesses say Olivia and Charlotte hold the Up gate open and wait whilst their Cambridge train passes over the crossing. They wait between the gate posts, at a point between the gate and the track.
The waiting girls are said to appear happy and excited – but not agitated.
3. Emergency brake
Olivia and Charlotte might now be thinking that the ongoing red light and single-tone alarm relate only to their Cambridge train. They watch as the train passes over the crossing and slows to stop at the Down platform.
Rossiter-Summers decelerates his train further to about 15mph (24km/h). The second coach of his four-car train is in the Down platform. Rossiter-Summers now sees the Stansted train approaching Elsenham on the opposite line.
10.40 – and 14 seconds: The southbound fast train, now on the curved Up line approach to Elsenham, is travelling at over 65mph.
The rear coach of the girls’ Down train passes over the crossing. The Cambridge train begins to slow to a halt at the platform. Moments before it comes to a stop, the Stansted train passes the Cambridge train.
The red lights remain lit and the yodel alarm still sounds.
“The express was past me, not even in a second,” says Rossiter-Summers, afterwards. “It was travelling so quick.”
Motorist Alison Dinsdale sees Olivia and Charlotte arm-in-arm. The crossing keeper also sees the girls go through the open gate.
Dinsdale sees them make a “dash for it”; for their Cambridge train now slowing in the Down platform diagonally ahead of the crossing.
Ian Potter is also there. “The red light was on,” says Potter. “The first girl opened the gate to go through and the second girl was one step behind her.
“They were trying to catch the train. I remember thinking they weren’t going to make it.”
The girls are now in the path of the second train.
Waters, driving the second train coming, first sees the Cambridge-bound train at the opposite Down platform. As the Stansted train rounds the left hand curve on the Up line, he sees cars waiting behind the road crossing gates.
Waters then sees two people on the crossing in front of his train, one behind the other.
“These two figures came out of nowhere,” recalls Waters. “They were right in the way on the track. They just ran straight in front of us.”
At 10.40 – and 15 seconds: “I put the emergency brake on,” says Waters. “I couldn’t stop.”
Waters applies a full emergency brake with the train speed recorded at 65.3mph (104.6km/h). The train approaches Elsenham crossing at a speed where 29 metres (32 yards) is travelled every second.
Even with the emergency brake applied, the train cannot stop. It clears the crossing in 1.8 seconds.
Less than half a second later, the miniature warning light returns to green.
The yodel alarm is silenced.
Waters makes an emergency call on the train radio.
Waters suspects his Stansted train has hit two people. He speaks to a Network Rail signaller at Liverpool Street and asks for all train traffic to stop. He tells the senior conductor on his Stansted train about the incident.
Waters draws his train forwards a short distance to the next signal with a signal post telephone. The driver descends to the track and heads for the phone.
Waters sees clear signs of an accident.
He gives details of the accident to a Liverpool Street IECC signaller. The recording of this conversation suffers from a fault in the voice recording machine.
The crossing keeper returns to his cabin. He removes the gate keys from the control panel. This means the signals are at red and no further trains can pass.
Rossiter-Summers and his instructor are aware that something has happened on the other line behind them.
He completes his usual departure checks. Their train leaves for Cambridge – without Olivia and Charlotte.
Witness Ian Potter, who saw Olivia and Charlotte in the moments leading up to the accident, says: “They were just a couple of girls, laughing and joking.
“They didn’t seem to have a care in the world.”
Witnesses and the train drivers – both Waters and Rossiter-Summers – suffer considerable trauma. As the Stansted train passed, Cambridge train driver Rossiter-Summers was occupied with releasing the doors and watching passengers getting on and off his train.
However, instructor Craig Swanick had lowered the window on the right side of the driving cab and looked back toward the crossing. The instructor thought the girls were in the ‘four foot’, the recess between the tracks and the platform edge – and that they were waiting for his train to pass.
This ‘momentary vision’ ended when the Stansted train passed and blocked his view. He then saw people running on the platform and heard shouting.
Rossiter-Summers and his instructor hear about the accident when they arrive at Cambridge. Both are upset and are allowed to go home.
Police, ambulance and fire service personnel are on site within minutes. A Rail Incident Officer arrives at Elsenham at 1120hrs. Police protect evidence by establishing a cordon around the site.
A British Transport Police officer accompanies the Stansted train driver. Another BTP officer boards the train to speak to its passengers.
A relief driver for the Stansted train arrives at 1235. Waters and the train conductor are taken home in a taxi 15 minutes later.
British Transport Police hand the site of the tragedy back to Network Rail at 1351. The Stansted train continues its journey at 1355.
Undertakers are expected at 1330.
A Network Rail contractor completes work by 1445. Normal line working is resumed.
Crossing keeper Joe Carriman is offered the chance to be relieved of his duties soon after the tragedy. Carriman is offered counselling but prefers to continue working and complete his shift.
Signalling engineers temporarily lock the footpath wicket gates out of use, ‘pending tests on the integrity of the crossing equipment’.
Timings later provided suggest Olivia Bazlinton and Charlotte Thompson stepped onto the crossing at the very second the alarms would have ceased as the Cambridge-bound train they intended to catch cleared the crossing. The implication is they did not realise a second train was approaching the crossing.
Charlotte and Olivia are the 123rd and 124th accidental deaths at level crossings in the UK since 1994. (This excludes suicides and suspected suicides).
Charlotte and Olivia are the 85th and 86th pedestrians to die accidentally at a level crossing and the fourth and fifth to die at footpath crossings fitted with Miniature Warning Lights.
The girls are the first people since 1994 to be killed at a station footpath crossing fitted with MWLs.
Their deaths are the first fatalities at Elsenham station since 20 November 1989 – when a train killed a 69-year-old woman, an intending passenger, on the footpath crossing.
A north London vicar regularly preaches that an average person living in Britain can expect to live for ‘three score and ten’, or 70 years.
“Maybe, it’s better to think of this as 25,550 days,” says the vicar.
Applying this, it means Olivia Bazlinton and Charlotte Thompson have lived just over 5,110 and 4,745 days respectively.
The families of Olivia and Charlotte are devastated.
Two balloons tied to the school railings, one pink and one scarlet, nudge each other in the breeze outside Newport Free Grammar School. Headteacher Richard Priestly offers pupils counselling after the tragedy. A deeply shocked Priestly says of the two girls: “They were full of life and had everything ahead of them.”
Mourners lay flowers, messages of remembrance and cuddly toys at Elsenham station over the next few days. Charlotte’s older brother, Robbie, 15, plays on his guitar, Time of Your Life, a song by the rock group Green Day, as he leads a spontaneous tribute to his sister Charlie outside Elsenham station.
Charlotte’s former Brownie leader Jennifer Jarvis says Charlotte was a “lovely girl” and “everyone warmed to her”.
Reg and Hilary Thompson, Charlotte’s parents, who live in nearby Thaxted, pay tribute to their “beautiful, vivacious and generous girl”.
A family statement says: ‘A fog of emptiness descended upon us. Our thoughts are with Olivia’s family – and the families of all those children who for no reason that we can think of are taken from us before their time.
‘We know that all around the world people suffer appalling misery every day. We are not singled out. Charlie will never leave us and we will never leave her. In her short life she brought happiness to so many. She was an angel.’
Hilary says: “You take the next breath because you have to. We are all lost without her. Charlie was the engine of the family…We live for our children…They are our life.”
Olivia’s sister Stephanie leaves a tribute at the scene of the tragedy: ‘RIP Olivia and Charlotte xxx. You will always be loved and never forgotten. Always in our hearts xxx Your heartbroken big sis.’
PART 4: Grief and anger 1. ‘Bear trap’ 2. Locks 3. 5th December re-assessment 4. ‘Safe, if used correctly 5. 1989 fatality 6. Occurrences 7. ‘Misuse’ 8. Gut instinct 9. Services 10. Further incidents 11. The Weir photograph
Grief and anger
1. ‘Bear trap’
Grief mixes with anger.
Reg Thompson labels Elsenham station’s pedestrian level crossing as a “bear trap in the woods”.
Thompson explains the girls were not trespassing, playing or hanging around on the railway. They were intending passengers with purchased tickets, using one of Network Rail’s risk assessed station footpath level crossings.
The families also criticise the absence of ticket machines on the Down platform. Cambridge-bound passengers, like Olivia and Charlotte, could have avoided the need to cross the tracks if the Down platform had a ticket machine and/or a ‘permit to travel’ machine.
A ‘one’ Railway Group Station Manager is responsible for ten stations, including Elsenham. She says the other nine stations similarly have sales facilities on just one platform. But footbridges connect platforms at every station – except Elsenham.
Chris Bazlinton, Olivia’s father, strongly echoes Thompson. “Of course, the girls made a mistake. They’re still only children. Olivia is not the only one who has attempted to cross the tracks with the pedestrian signals still at red – commuters can be seen running across most days,” says Bazlinton.
He remains adamant Olivia and Charlotte would still be alive if the pedestrian gates had locked – either manually or automatically in tandem with train signals that indicate an approaching train. “If the pedestrian gate had been locked Olivia and Charlotte would not have crossed. They’d have laughed it off, and waited for the next Cambridge train,” says Bazlinton.
Other people tell Bazlinton in the days and weeks after the tragedy they too have crossed the tracks when the red light shows. “You can push the gate open at any time,” he says.
Olivia’s father is also sure the girls would still be alive if the level crossing had been equipped with a second, differently sounding alarm that would have enabled the girls to distinguish between their 1041 train halting at the Down platform and that second rapidly approaching fast train. “If a second, different sound had gone off, I know again, they wouldn’t have crossed,” says Bazlinton.
Similarly, he feels the girls would not have stepped onto the crossing if a spoken message about the ‘second train coming’ had sounded.
Reg Thompson recalls claims by Network Rail, made in the aftermath of the tragedy, that the girls had acted recklessly and that somehow their youthful exuberance had led to their deaths.
“I never believed that Charlie and Liv were the architects of their own terrible end,” says Thompson later.
Three thousand people sign a petition in the Herts & Essex Observer demanding Network Rail fit locking pedestrian gates.
“The deaths of Charlotte and Olivia were a tragedy, and will never be forgotten,” says Jon Wiseman, Network Rail’s Anglia route director.
In the aftermath of the December 2005 tragedy, national media reporters and specialist railway journalists focus on whether locking gates could have prevented the deaths of Olivia and Charlotte.
Network Rail insists locking gates might trap people on the tracks between the gates.
Chris Randall, editor of Rail Professional magazine, writing in May 2006, disagrees and responds: ‘There is a recess (next to the tracks) at Elsenham where anyone in danger can take refuge.’
Randall, a seasoned rail industry observer, adds: ‘A simple lock, operated either manually or automatically when a train is approaching, would have almost certainly prevented the deaths of Olivia and Charlotte.’
The widespread expectation after the December 2005 tragedy is for Network Rail – as crossing provider – to take prompt commonsense action to make Elsenham’s pedestrian level crossing safer for crossing users.
Train drivers report three near misses involving pedestrians that were logged by Network Rail. But the drivers claim no action was taken.
Crossing keeper Joe Carriman tells British Transport Police: “I don’t know what the bosses will do. I think they should lock the pedestrian gates as they did the main (road) gates.”
Central Trains subject their lead Stansted unit 158856 to an independently verified technical investigation. The unit’s braking performance meets the required standard.
3. 5 December re-assessment
On 5 December, two days after the deaths of Olivia and Charlotte – and as national media cover the tragedy – Network Rail re-assesses risks at the station and acknowledges that Elsenham has the third highest risks at any station pedestrian crossing in the United Kingdom.
The April 2005 assessment had accorded Elsenham a risk score of 28 – meaning a level of risk requiring no safety improvements. But the 5 December re-assessment scores Elsenham at ‘47’, meaning extra safety measures should be considered in accordance with rail industry standard G1/RT7011. Only footpath crossings at Crowle (48) and Downham Market (53) score higher.
A glaring disparity now arises between the April assessment score of ‘28’ and the December re-assessment tally of ‘47’. The station pedestrian crossing has not changed during the period between the two assessments.
Later, it transpires the differences arise due to incorrect scores for ‘frequency of misuse’, ‘frequency of use’, ‘number of trains’, and ‘probability of stepping out from behind a train’.
The main difference is said to arise because the crossing keeper questioned in April did not inform the risk assessor about the frequency of misuse. This frequency could have been established from the daily log of events – if the instances of ‘misuse’ noted in the keeper’s Occurrence Book had also been reported to the controlling signaller.
The daily log would also have allowed ‘misuse’ instances to be included in the railway industry’s national Safety Management Information System database. SMIS data can trigger safety reviews.
The re-assessment of Elsenham shows specific factors may increase ‘misuse’, including an intending passenger’s wish to catch a particular train, and, the requirement of Cambridge-bound passengers to buy a ticket from the booking office or from one of the machines located only on the Up platform.
Cambridge-bound passengers travelling without a ticket are also likely to incur a penalty fare – so they must cross to the Up platform to buy a ticket and then cross back over the tracks to catch their train.
4. ‘Safe, if used correctly’
However, it is now acknowledged after the tragedy that the semi-quantitative risk assessment scoring method is not sufficiently sophisticated to record such ‘local factors’. Only the awareness and skill of each risk assessor can identify and take these factors into account.
Accident investigators describe the risk assessment scoring system as ‘not a sophisticated tool’. Certain assessment criteria depend on ‘the judgment of the assessor’.
Investigators also find the quantitative risk assessment method is ‘a temporary solution…prior to the development of a more sophisticated quantified tool, the All Level Crossing Risk Model (ALCRM). Work on this model is currently in progress’.
This implies Olivia and Charlotte have used a level crossing where risk is assessed by an unsophisticated and stop-gap method – whilst a newer, more refined model is still being developed.
But, despite growing recognition of emerging flaws in Network Rail’s risk assessments of Elsenham, the company publicly persists with a mantra that the Elsenham crossing is safe, if used correctly.
This stance is seen as clearly implying the girls are to blame for failing to abide strictly by ongoing crossing warning lights and the alarm.
Network Rail also says installing a footbridge would be unjustified and too expensive.
5. 1989 fatality
The deaths of Olivia Bazlinton and Charlotte Thompson are the first fatalities at Elsenham station since a train killed a 69-year-old woman, an intending passenger, on the footpath crossing on 20 November 1989.
The woman had stepped out behind a stopping train. She had tried to use the footpath crossing from the Down side towards the Up side. She crossed while the MWL showed red, possibly believing the red light related to the stopping Down train that had passed over the crossing – and not to the possibility of a second train coming on the Up line. A coroner’s verdict was accidental death.
The local parish council expressed concern about the position and visibility of the warning lights – and the warning time given of approaching trains. British Rail, then in control of the UK’s rail infrastructure, measured train speeds, warning times and observed the crossing’s operation. BR said the warning lights and times conformed to Her Majesty’s Railway Inspectorate’s requirements.
HMRI inspected Elsenham level crossing in February 1990 and decided to make minor changes to the footpath crossing’s layout, to reposition the MWLs and remove redundant warning signs. Nobody suggested locking the wicket gates.
It was decided to fit an audible yodel alarm to supplement the red light warning.
HMRI and BR also agreed a second tone alarm should be installed so that ‘the second train situation should be reflected by a hurry nature in the tone of the alarm’. All of the modified recommendations were implemented during 1990 – except the second tone audible alarm to warn of a second approaching train.
Between 1990 and 2005, the crossing remained unchanged.
In the weeks and months after the December 2005 tragedy, anecdotes emerge that crossing users of all ages have – since 1989 – frequently crossed the line when the red light shows and the yodel sounds.
Crossing keepers maintain Occurrence Books kept in the keeper’s cabin. Many entries relate to public ‘misuse’ of the crossing. One keeper makes few entries. Another makes occasional entries whilst a third makes numerous.
All keepers make entries about individuals crossing against the red MWLs. Many relate to teenagers’ behaviour on the crossing and around the station. Frequent comments are made about teenagers travelling without a ticket.
Eleven ‘Occurrence’ Books’, analysed after December 2005, record 303 such ‘misuse’ instances between 10 April 1999 and 6 December 2005 – the latter three days after Olivia and Charlotte are killed. Of these, 140 involve adult men, 44 adult women, 61 boys and 26 girls. The rest involve mixed groups or the gender is not identified. More than 90% are people who start to cross after the lights turn red.
Accident investigators believe the actual occurrence of ‘misuse’ of the station footpath crossing is even higher than the books show.
The term ‘misuse’, in the context of level crossings, is used by the railway industry to cover both intentional and unintentional use of a crossing, particularly when visual and audible warnings indicate it is not safe to cross the lines. Unfortunately, the term creates confusion and breeds complacency about the risk posed by certain level crossings, such as Elsenham,
Worryingly, many people continue to either unintentionally or deliberately misuse the Elsenham crossing after December 2005 and well into 2006.
Forced to use the road crossing whilst the footpath crossing gates are temporarily locked ‘pending investigations’, some pedestrian users are observed impatiently climbing over the closed road gates to reach the opposite platform. They do so despite verbal warnings from Network Rail staff and irrespective of floral tributes in memory of Charlotte and Olivia.
Three instances of ‘misuse’ are recorded during a 20-day period after the accident when the crossing is under scrutiny, including a period of video surveillance.
8. Gut instinct
Just a few days after the December 2005 tragedy, Christian Wolmar, one of Britain’s leading transport commentators and historians, visits Elsenham and writes: ‘The whole feel of the crossing was something out of the Railway Children film, perfectly suitable for a branch line with a few trains per day, but not for a busy line with up to eight trains an hour including freight.’
Wolmar accepts each risk has to be scored scientifically and expressed mathematically. But he adds: ‘There is, too, a role for gut instinct and that is sometimes lost in the fug of rules, procedures and regulation that now govern everything on the railway.
‘Just one glance at the crossing with its badly painted wobbly line on the tracks and the cute little latch-less wicket gate, which offers no hint of the dangers posed by the location, should be enough to make any concerned railway manager gasp in disbelief…The principle of making risk ‘as low as reasonably possible’ seems not to have been applied sensibly here.
‘I suspect there will be major changes at Elsenham, too late for the two girls.’
A special memorial thanksgiving service celebrates the lives of Olivia and Charlotte. Hundreds of people gather for the service at St Mary the Virgin church at Newport on 19 December 2005. A cremation service for Olivia takes place afterwards.
Olivia Bazlinton’s funeral takes place on year later at St Mary’s Church, Newport, on 24 February 2007.
‘So many smiles, So much laughter, So much fun, So much love,’ reads an inscription.
10. Further incidents
Four months after the tragedy, the author visits Elsenham on a cold Tuesday evening in March. Writing for Rail Professional magazine in May 2006, the author observes further incidents:
‘I hadn’t been there long when I saw an elderly woman crossing whilst the warning light was showing red,’ writes Paul Coleman. ‘She tugged in vain at the hinge end of the wicket gate. The gate has no handle to pull, so it’s an easy mistake, particularly at night for someone partially sighted. After a few seconds, she turned and managed to open the gate before hobbling slightly across the tracks. The train came through about 50 seconds later.
‘Risk-taker number two was a middle-aged commuter, booted-and-suited with briefcase. He cut it finer, opening the unlocked gate and crossing whilst the red light was on and the warning alarm was sounding. The train came through about 30 seconds afterwards.
‘Later, a down line train arrived and stood at the platform. A second up line train was also approaching but there was nothing distinctive to signal that the latter train was approaching. The driver sounded his horn. Drivers had expressed worries about Elsenham before.
‘It is understood that a train driver who lives in Elsenham has written to the route manager (at Network Rail) to install whistle boards that would tell drivers to sound their horns. Now, it seems drivers ignore residents’ noise concerns and routinely sound their horns.
‘Half-an-hour later, the road barriers were closed once more. The red light glowed in the gloom and the alarm was sounding. A teenage boy standing on the village side of the tracks, clutching a football, opened the gate and stood close to the cess rail, glancing up and down the tracks. His mates, standing on the Up platform, called to him. One of them, a can of Special Brew (strong lager) in his hand, then tried to dissuade him from crossing.
‘The lad with the ball stared for a few seconds back along the downline. He leant forward, almost over the cess rail (the rail closest to the recess area beside the tracks). He stepped back through the wicket gate and waited for a Down train to pass. Instead, an Up London-bound train raced through. More by luck than judgment, ‘there but for the grace, went he.’
11.The Weir photograph
Photographer Simon Weir, on another day in Spring 2006, then photographs two boys racing across the tracks after the audible alarm sounds (see photo above). Drivers watch the boys from their cars that queue safely behind vehicle gates closed several minutes earlier by the crossing keeper.
Between the tragedy and May 2006, journalists and rail officials reportedly witness at least six incidents of people crossing when trains are approaching.
In June 2006, a 12-year-old boy reportedly gets off one train and is almost struck by a second train coming as he runs over the crossing.
Of Network Rail’s failure to take basic remedial safety measures in the aftermath of the December 2005 fatalities, Chris Randall of Rail Professional adds, prophetically: ‘Network Rail’s failure to take even the most basic and obvious steps to prevent another Elsenham is at best incompetence, at worst complacency – and Network Rail should not be surprised if, once investigations have been completed, it finds itself facing formal accusations of negligence.’
PART 5: Network Rail – the company 1. Families and Network Rail 2. ‘Hybrid’ organisation 3. Fragmentation 4. Hatfield and Potters Bar 5. Accountability and Transparency 6. Finance 7. John Armitt
Network Rail – the company
1. Families and Network Rail
The families of Olivia Bazlinton and Charlotte Thompson now encounter Network Rail.
Several individuals who represent the company, including executive members of the board of directors and West Anglia route managers and staff, meet face-to-face with the girls’ parents.
In October 2002, Network Rail takes over ownership and operation of Britain’s rail infrastructure from Railtrack, a private company with shareholders.
The Treasury funds Network Rail with taxpayers’ money. Network Rail also levies track access charges on the UK’s private train operating companies. The company re-invests profits, after interest payments, in the UK rail network.
Network Rail is also a private company but there are no shareholders to hold its board of directors to account.
John Armitt was appointed Railtrack chief executive in December 2001 – when Railtrack was in administration. Later, Armitt is appointed as Network Rail’s first chief executive in October 2002 on £450,000 a year. Iain Coucher, as deputy chief executive, starts on £400,000.
Operational decisions are delegated and organised into different ‘routes’. These broadly mirror the privatised train service franchise areas.
Robin Gisby, as operations and customer service director, is responsible for running the railway on a daily basis – chiefly tasked to ensure the rail network enables the private train companies to operate their services on time.
2. ‘Hybrid’ organisation
Network Rail is a ‘hybrid’ organisation – a publicly funded private company without dividends and shareholders. Some rail industry observers believe Network Rail befits the old phrase, ‘a camel is a horse designed by a committee’.
The ‘camel and committee’ jibe might also describe the post-war management and re-organisation of the UK’s railways since 1945, of which Network Rail is the latest manifestation.
Britain is globally recognised as the country that invented railways. But incompetence and ideology combine to hamper Britain’s own railways, a unique system built and evolved chiefly by rail staff and managers over the best part of 200 years.
Railways ‘greased the rails’ for the United Kingdom’s Industrial Revolution, pardon the pun. Railways enabled the UK to become the world’s first nation to undergo a transformation from a predominantly agrarian and rural society to an industrial and urban political economy.
In 1994, Britain’s rail network includes 11,000 route miles of tracks with signalling, 40,000 bridges, tunnels and viaducts, 2,500 stations, and over 7,000 level crossings.
Elsenham’s station footpath crossing is one of the rarest sub-species in Britain’s railway ecology. Some of its risk-laden weaknesses and unorthodox configuration in December 2005 can be traced back to the Victorian origins of the railway – and others to the legacy of compromises and traumatic upheavals imposed on the railway system since 1945.
The station originally opened during the early Victorian era when private capital controlled by private entrepreneurs built Britain’s railways. Cost-cutting, landownership and sheer inefficiency led to many unnecessary curves on routes and to the inconvenient location and poor layout of some stations.
A laissez-faire ethos dominates the first 110 years of the UK’s railways. Regulation through law and formal standards consistently reacts to problems, risks and accidents on the railways, rather than proactively identifying, managing and mitigating risks. Legislators respond to the rapid growth of the railways in ways that might be compared to the way lawmakers vainly try to regulate the Internet in the 21st Century.
However, Victorian lawmakers do manage to enact railway laws to regulate safety and create an embryonic railway inspectorate. They establish the 4ft 8 ½ inch uniform gauge – the width of separation between two rails.
Railway accidents over several years with similar causes lead to safety improvements. The Regulation of Railways Act 1889 swiftly follows the Armagh disaster in June 1889. A train stalled on a hill was split in two. The rear section, without continuous brakes, slid down the hill and smashed into another train on the way up. Eighty people died and over 150 were injured.
Armagh leads to an Act that insists interlocking and block signalling must be installed to avoid two trains being allowed to proceed into one track section. Automatic continuous brakes were introduced throughout trains.
Yet the pattern of incidents and accidents prompting reactive safety improvements continues into the period after World War II when the railways are nationalised and controlled by government.
Passengers and railway workers experience nationalisation after World War II in the form of British Rail. Rationalisation, with Richard Beeching’s proposed line closures, follows in the 1960s.
British Rail then suffers from a chronic lack of investment – and becomes demonised by the media and derided by the British public. For instance, Elsenham bears a possible trace of this underinvestment after the 1989 fatality – British Rail fails to improve ‘second train coming’ audible safety warnings as recommended by accident inspectors.
Overall under-investment during the 1970s and 80s is then compounded between 1996-2005 by a dysfunctional privatisation of the UK’s railways. On 5 November 1993, the Conservative government led by Prime Minister John Major privatises the UK railway network through the Railways Act 1993. The last British Rail train runs in 1997.
Integrated control of tracks and trains is replaced with separately controlled track and trains. The rail industry experiences fragmentation and excessive complication. Private companies seek profits from running train services.
Publicly-run British Rail business sectors – Intercity, Regional Railways, Network SouthEast and ScotRail – are replaced by private train operating companies that are awarded franchises.
Railtrack replaces British Rail as the owner and operator of the railway tracks and supporting infrastructure. Railtrack – a newly created private company – and its contractors seek profit for their shareholders from infrastructure maintenance and renewal. Railtrack is essentially a private ‘outsourcing’ company, with little in house engineering know-how and no research wing.
4. Hatfield and Potters Bar
Fragmentation leads to a dysfunctional – and some say broken – system of railway maintenance and track renewal.
Four men are killed at Hatfield in October 2000 when a train derails on rails left broken by Railtrack’s excessive bureaucracy and its poor ‘interfaces’ with private companies undertaking track maintenance.
A similar matrix, involving Railtrack and maintenance company Jarvis, contributes to seven people being killed at the terrifying Potters Bar derailment and crash in May 2002.
After Potters Bar, Railtrack plummets towards financial liquidation – although its shareholders will later be compensated for railway assets soon to be taken off them. Potters Bar also spurs re-organisation just after the turn of the Millennium. Re-organisation leads to the creation of Network Rail.
At first glance, Network Rail seems to be a renationalisation. The company pursues reintegration – bringing back in house some £1.2 billion of railway maintenance work hitherto undertaken, under Railtrack, by large private contractors, such as Amec, Amey, Balfour Beatty, Carillion and Jarvis. Some 16,000 workers, over 5,000 road vehicles and 600 properties now come under Network Rail’s direct control in July 2004.
However, the New Labour government – including Prime Minister Tony Blair and Gordon Brown – remain wedded to a pro-private sector ideology. With rail, they try to run with foxes and hunt with hounds. They blame a botched privatisation for the severe performance and safety problems facing Britain’s railways. But they argue renationalisation is not the solution.
A messy compromise envelops the railways. Private companies run train services through relatively short and competitively tendered franchises. Banks effectively take over British Rail trains and, via rolling stock leasing companies (ROSCOs), lease them to train companies for profit.
5. Accountability and transparency
The way Network Rail deals with the families of Olivia Bazlinton and Charlotte Thompson in the aftermath of the Elsenham tragedy raises concerns over the company’s accountability and transparency.
In 2002, New Labour politicians classify Network Rail as a ‘private non-financial corporation’ – a publicly funded yet private company with no shareholders. They herald this absence of an ‘equity buffer’ at Network Rail as virtuous, claiming it eliminates potential conflicts between profit and safety.
Network Rail’s debts – as a private company – will stay off the government’s own Treasury balance sheet. Politicians say this keeps pressure off the railways to cut expenditure. But taxpayers are still liable for Network Rail’s debts. As voters, they know the Treasury’s books are incomplete without that debt.
Network Rail, says New Labour, will be accountable not to profit-seeking shareholders but efficiency-seeking ‘stakeholders’. Later, the company’s board of directors becomes nominally accountable to 100 ‘members’ tasked to question directors when Network Rail falls below ‘high standards of corporate governance’.
Members have no financial stake and receive only travel expenses. ‘Industry members’ represent passenger and freight train operating companies and infrastructure manufacturers. ‘Public Members’ come from passenger groups, industry interest groups, and some are individuals.
A Membership Selection Panel of up to five people appoints members. But the Selection Panel itself is appointed by the Board of Network Rail, an arrangement believed to thwart the appointment of members likely to challenge senior executives and managers.
The company holds an annual general meeting, produces an annual report and accounts, and publishes a yearly business ‘Delivery Plan’.
But Network Rail is not open to outside scrutiny under Freedom of Information law.
The company is not directly accountable to elected government ministers.
The matter of where Network Rail gets its money from intensifies concern over the company’s lack of formal accountability.
The UK government’s Transport department is a Network Rail ‘member’. Headed by a senior cabinet minister, the department provides Network Rail with taxpayer-funded credit for capital expenditure on railway infrastructure – and for the re-financing of existing debt.
Network Rail can raise money itself by investing in bonds on capital markets and by taking a punt on riskier financial derivatives.
But the company receives over £4 billion each year from taxpayers.
The Office of Rail Regulation, the body that regulates rail finance and safety, determines the company’s finances over five year control periods.
Not surprisingly, Network Rail carries an AAA credit rating as its finances enjoy a UK government guarantee. The burden of this guarantee falls upon UK taxpayers.
Network Rail also receives up to £2bn more from charges levied on the UK’s private train operating companies. Train operators cover these charges by passing these costs onto passengers in the form of annual train fare rises. Taxpayers, this time as fare-paying passengers, therefore further subsidise Network Rail.
Railtrack shareholders were compensated – despite the company’s failings. Network Rail also takes over Railtrack’s £7.1bn debts. Taking into account other loan facilities and future borrowing, Network Rail is expected to rack up its own debts of up to £21bn.
By March 2006, Network Rail debt stands at £18 billion, up £2.4 billion from March 2005.
7. John Armitt
In July 2006, the families of Charlotte Thompson and Olivia Bazlinton privately meet Network Rail chief executive John Armitt near Stansted Airport.
Armitt is credited for Network Rail increasing the number of trains running on time in the UK by over 10%. Some £13.5 billion has been invested in the railways during Armitt’s tenure and he is also commended for ‘delivering £1.1bn efficiency savings’.
Armitt established his career as a civil engineer working for John Laing Construction on power stations, oil rigs, petrol-chemical plants, airports, roads, bridges and hospitals. In 1993 he becomes chief executive of Union Railways, responsible for the Channel Tunnel Rail Link.
In 1997 Armitt receives a CBE (Commander of the Order of the British Empire) award in the Queen’s Honour’s List for his contribution to the rail industry. He rejoins the construction industry in 1997 as chief executive of Costain before returning to the railways in 2001-02.
Armitt’s Network Rail biography describes him as a ‘life-long Arsenal supporter’, with ‘a son, daughter and two grandchildren’.
During their meeting with Armitt, the families of the two girls talk to him about their campaign to get the footpath crossing gates locked at Elsenham.
Armitt repeats Network Rail’s position – Elsenham station footpath crossing is safe, and the company will not install locking gates.
Tina Hughes, Olivia’s mother, recalls: “He said to us, and I quote him almost verbatim because I can honestly hear him saying the words to me, ‘We have to consider the cost of safety versus the value of life.’
“I found that an absolutely inhuman way to speak to me as a bereaved parent,” says Hughes of Armitt.
In December 2006, Network Rail announces John Armitt’s intention to retire as chief executive in the summer of 2007.
Iain Coucher will replace Armitt.
PART 6: RSSB investigation 1. RSSB 2. Train horns 3. RSSB speculation 4. Emphasis on personal responsibility 5. ‘Misuse’ type 6. RSSB on closure 7. RSSB on footbridge 8. Yodel alarms 9. RSSB on ticket sales 10. Occurrence Books 11. RSSB on risk assessment 12. RSSB on causes
The Rail Safety and Standards Board is the first body to officially report after formally investigating the Elsenham fatalities of December 2005.
Established in April 2003, the RSSB is a not-for-profit company funded jointly by railway companies and by government. The company aims to promote rail safety improvements by developing long-term strategies, setting standards, helping operators achieve safety targets, and to report progress on specific areas of rail safety.
The RSSB publishes its Elsenham report in May 2006, in accordance with Railway Group Standard GO/RT3473.
The report includes a prefacing statement. ‘The inquiry has been conducted with the objective of determining the facts of an accident, the immediate and underlying causes and of making recommendations to prevent, or reduce the risk of, recurrence…The objectives of this inquiry were not the allocation of blame or liability.’
The RSSB inquiry objectives include addressing ‘the industry arrangement for managing the risks, including risk assessment, at this type of crossing’.
The personnel involved in the inquiry include an independent chairman and an ‘inquiry panel’ consisting of ‘representatives from Network Rail, ‘one’ Railway and Central Trains’. A specialist advisor – an ‘independent human factors expert’ – is also included.
The panel is said therefore to consist of Jim Ward (independent chair), Wallace Weatherill (Head of Operational Safety Policy, Network Rail), Andy Sanders (Head of Safety and Environment, ‘one’ Railway), and Peter Frost (Head of Safety, Central Trains).
2. Train horns
The RSSB report considers the driver of the Stansted train sounding the warning horn.
In 2003, railway managers across the country received numerous complaints from local residents about noise disturbance from train horns. Train drivers were required to sound horns as they approached a station.
The requirement to sound a horn when passing another train in a station had been in the railway rule books since at least 1933. In some instances following complaints, noise abatement orders were served on the railway. By December 2003, the requirement to sound warning horns was removed.
The RSSB says no incidents occurred on the railways between December 2003 and 3 December 2005 that were related to the removal of the train horn sounding rule.
However, the RSSB’s inquiry panel does consider possible scope for ‘a local instruction concerning sounding horns when passing trains in station with a station footpath crossing, particularly with pedestrian gates which are not locked’.
3. RSSB speculation
The RSSB report also says each evening on coming home from school, either or both Olivia and Charlotte used the crossing from the Up platform towards the village.
The report speculates: “It was familiar situation and they may have been accustomed to seeing a green light and passengers crossing to catch a Cambridge train after it had arrived in the platform.
‘On the Saturday morning they were therefore in a familiar situation, their only thought was of their train, which they could see arriving. They would know that there would not be another train to Cambridge for an hour and also that trains departed as soon as passengers had boarded giving little time to get from the Up platform, across the lines, over the road and along the Down platform to the train.
‘There was evidence that the girls were familiar with the station and may have seen adults crossing the railway when the MWLs were showing red and the yodel alarms sounding.’
4. Emphasis on personal responsibility
The RSSB report conjectures about how safe Elsenham is for its pedestrian users and intending rail passengers. Most must cross over the lines at either the beginning or the end of their journey.
The tone of the RSSB report typifies the rail industry’s cautious approach to adopting new safety measures and the lingering emphasis on the notion of ‘personal individual responsibility’. For instance, the report states: ‘It is a matter of debate whether or not they (Elsenham crossing users) should be entitled to a greater level of protection than other crossing users and if they too carry personal responsibility for using the crossing safely.
‘Clearly, there is an issue of personal responsibility. The warnings and signage are used by the majority safely, but whether the current system is appropriate in a case where the station access facilities are via a level crossing with no alternative is an issue that requires resolution.’
The RSSB states: ‘The present design of Elsenham crossing gives a balance between minimising inconvenience to users and their safety, providing the user observes and obeys the instructions and warnings.’
But the report adds: ‘The crossing at Elsenham has suffered misuse for many years…With the present safety arrangements at the crossing, emphasis must be placed on user responsibility for crossing safely and the role of adults in setting an example to the many children who use the crossing.’
5. ‘Misuse’ types
The RSSB dwells upon making distinctions between different types of crossing ‘misuse’.
Intentional misuse involves crossing after a willful disregard of warnings and instructions.
Unintentional misuse involves crossing after misunderstanding warnings and instructions not to cross.
Impulsive misuse occurs when a users decides to cross as soon as a train is clear of the crossing without waiting for the lights to change and the yodel warning alarm to stop.
Unintentional and impulsive misuses can be reduced or prevented but irresponsible intentional misuse is impossible to eliminate.
In the context of Elsenham, the RSSB says ‘the wicket gates are free to open while the MWLs are showing red, and do not, therefore, prevent intentional and unintentional misuse of the crossing’.
Clearly, although the report does not state it, non-locking gates also fail to prevent impulsive misuse.
Earlier, in June 2004, the RSSB published research into the ‘behaviour’ of crossing users at users worked crossings. Human Factors Assessment of the Risk Associated with MWL Crossings proposed wider studies into how crossing users understood audible alarms and on the effectiveness of ‘one-way locking gates’.
The RSSB considers options to make Elsenham station footpath crossing safe. The report of the RSSB panel into the Elsenham tragedy notes closing of a crossing is ‘if, possible and reasonably practicable, always preferred by Network Rail’.
6. RSSB on closure
But the RSSB report says closing Elsenham’s footpath crossing so pedestrians would use the adjacent road crossing is ‘not sensible’, as ‘the road layout places users of the crossing in greater danger from road vehicles’.
The report adds: ‘Closure of the footpath crossing should only be considered if there would be no intolerable increase in overall risk to users.’
7. RSSB on footbridge and locking gate
The RSSB sits on the fence over whether a footbridge would improve safety at Elsenham. It cites ‘space limitations and cost’ as making a footbridge ‘unsupportable’; and concludes only with a general point that ‘safety improvement expenditure is related to the reduction in risk achieved’.
The RSSB seeks advice from officials at Her Majesty’s Railway Inspectorate about locking the gates. The RSSB panel report quotes HMRI guidance that says wicket gates must be free to open when positioned with MWLs – chiefly to avoid the risk of trapping someone on the crossing.
The RSSB adds a ‘safe and highly reliable mechanism of providing a safe means of escape would have to be in place’ if wicket gates at Elsenham were to be locked.
The RSSB does advocate video surveillance to deter intentional misuse and identify unintentional misuse.
But it believes assigning a more active role to the crossing keepers at Elsenham for the footpath crossing would distract them from their primary role to operate the road crossing in a timely way to prevent delays to road users and rail passengers.
8. Yodel alarms
The RSSB ponders why no work was carried out to enhance the standard yodel alarm at Elsenham to one that sounds a different ‘second train coming’ tone.
After the death of an elderly woman at the crossing in 1989, HMRI reached an agreement with British Rail that the station footpath crossing would be fitted with a distinctive audible warning to alert users to the approach of a second train.
The RSSB says it cannot establish why the agreed work was not done. It speculates the reason might have been the ‘significant signalling changes necessary’.
The RSSB report notes second train warnings are considered necessary for automatic road level crossings. Both road users and pedestrians at this other type of crossing can hear these warnings.
In the context of the Elsenham tragedy, the report states: ‘A second train tone may have alerted others nearby, including the crossing keeper, giving them the opportunity of warning the girls at that moment.’
A distinctive ‘second train coming’ tone, if it had been installed at Elsenham as agreed in 1990, would have sounded as the first train – the Cambridge service – had arrived at the crossing. This would have given everyone at the crossing, including Olivia and Charlotte, 13.1 seconds warning of the approach of the Stansted train.
The RSSB seems to advocate the installation of alternative second train warnings, such as a recorded spoken warning. ‘It will still leave the user to make the final decision on when to cross safely but with additional information to guide the decision,’ says the report.
9. RSSB on ticket sales
The RSSB Panel says installation of a permit machine on the Down platform would mean Cambridge-bound passengers would no longer need to cross the lines.
‘The provision of additional ticket facilities…would reduce the number of times intending passengers have to cross the tracks and remove some of the time pressures created by the current provision of ticketing facilities on only the Up platform,’ says the RSSB report.
‘For the two girls it may have removed the necessity to cross the tracks on their outward journey,’ the report concludes.
10. Occurrence Books
The report notes there remains no means of transferring information on crossing misuse from the crossing keepers’ Occurrence Books to the SMIS. Keepers do not report misuse to controlling signallers.
11. RSSB on risk assessment
The RSSB considers previous risk assessments of Elsenham but draws few conclusions about them.
It does say assessment ‘merits a significant weighting to take account’ of misuse encouraged by ‘one’ Railway’s penalty fare system, ‘the short time available to board trains, the infrequent off peak service, and the possibility of being delayed at the crossing by through and stopping trains’.
Paragraph 8.5.2 adds: ‘Vulnerable users such as elderly passengers and possibly children are weighted lightly at only six per cent of the total. This may be a particular issue at Elsenham because of the school journeys made to Newport.’
However, the report, at this point, does mention the risk assessment 28-47 score discrepancy between Network Rail’s risk assessments of April 2005 and December 2005, the latter conducted after the tragedy. But the RSSB does not comment on risk assessments conducted at Elsenham prior to 2005.
In the second of nine recommendations, the RSSB says Network Rail should ‘commission a quantitative risk assessment at Elsenham and the other 13 station footpath crossings with MWLs’ to see if any further ‘reasonably practicable options’ exist to minimise the risk to users.
These options include consideration of the ‘implications of closure, provision of a footbridge, minimising need to cross the tracks, securing wicket gates, improvements to MWLs, audible warnings including train horns, ‘Another Train Coming’ warning, and ‘signage appropriate to MWL crossings’.
12. RSSB on causes
The RSSB Panel report concludes with one immediate cause and four underlying causes of the Elsenham fatalities. The RSSB says the immediate cause is ‘the two girls did not react to the red miniature warning light and yodel alarm, which visually and audibly indicated that it was not safe to open the wicket gate and cross the tracks’.
The RSSB does not convey in its report witness evidence that the girls did abide by the warning lights and alarm and wait before crossing. The report does not focus on the strong possibility that the girls crossed after their train had passed over the crossing, believing the warnings related to their train and gave no specific warning of the approach of the second train.
The RSSB say the underlying causes are:
‘the ability to open the wicket gates and cross the lines when it was not safe to do so’
‘necessity for Cambridge passengers, not in possession of a ticket, to make a purchase on the Up platform and then cross to the Down platform’
‘insufficient time allowance by the girls to purchase tickets and board the train to Cambridge’
‘possible influence on the girls of misuse of the crossing by other, older users’.
The RSSB publishes its report in May 2006.
PART 7: RAIB investigation 1. RAIB 2. Sighting times and line 3. Network Rail reversal 4. Risk assessment failures 5. Ticket machine installation 6. ‘Don’t Run the Risk’ campaign 7. RAIB publication 8. ORR – the Regulator 9. ‘In the Line’ 10. ALCRM
The Rail Accident Investigation Branch functions as the UK’s independent body to investigate railway incidents and accidents.
The Rail Accident Investigation Branch’s roles and duties are set out in the Railways and Transport Safety Act 2003. The Act carries out a European Railway Directive (2004) requiring each European Union member state to set up a national rail safety authority and an independent rail accident investigation body.
The Office of Rail Regulation (ORR) and the Rail Accident Investigation Branch (RAIB) start to perform these respective functions in the UK.
RAIB chief inspector Carolyn Griffiths says: “The criteria for an investigation, apart from European Union mandates, is whether we can significantly learn about safety from an incident. For instance, if someone has deliberately put themselves at risk – by playing chicken on a crossing – it would be unlikely that we’d investigate if that was certainly the case.”
The RAIB becomes operational in October 2005. The Elsenham tragedy is one of its first major investigations.
The RAIB’s report, published in December 2006, states: ‘The risks at Elsenham are likely to be amongst the highest at any station pedestrian crossing on the UK mainline network.’
The report also identifies causes of the December 2005 tragedy. ‘The most likely explanation…is that the girls’ strong motivation to catch the train to Cambridge, and a high degree of distraction, made them temporarily unaware of the risks posed by the Up line. In addition, it is likely that the girls assumed that the audible alarm related only to the train that was passing ahead of them.
‘It is not possible to draw a clear link between the girls’ state of mind and their subsequent error,’ adds the RAIB.
But the RAIB identifies some contributing factors.
‘Firstly, users can walk onto the line when a train approaches because the gates do not lock. The warning signs and systems at the crossing did not deter the girls from stepping into the path of the second train,’ adds the RAIB report.
Signage at Elsenham fails to refer to the possibility of second trains approaching on the other line. Such warning signs are routinely provided at automatic vehicle crossings on double track railways.
‘Since one of the girls was a regular user of the crossing, it is possible that the inclusion of such a message would have made her more aware of this risk on the day of the accident,’ says the RAIB report.
‘The broadcast of a distinct second alarm or the transmission of a spoken message, possibly linked to the opening of the gate, may have prevented the two girls from preceding into the path of the second train,’ adds the report.
2. Sighting times and line
The sighting line and sight time from the position by the Up pedestrian gate are also factors. ‘It is possible that the concrete post momentarily interrupted their sight line,’ say investigators.
The RAIB report states plainly: ‘It is possible that the presence of a ticket machine on the Down platform would have avoided the need for the girls to cross the line.’
3. Network Rail backtrack
The ongoing investigation by RAIB principal inspector Simon French and his colleagues reportedly compels Network Rail to backtrack on its stance on risk levels and safety measures at Elsenham.
In September 2006, as the ongoing RAIB investigation focuses on the dangers at Elsenham, Network Rail reverses a major part of its original post-accident position. The company announces it is now going to recommend installing pedestrian gates that lock when the crossing keeper closes the road gates.
‘The presence of the crossing keeper when the wicket gates are locked will ensure no-one will be trapped,’ says Network Rail.
A footbridge will also be installed to maintain access over the railway when the pedestrian gates are locked.
“The recommendations represent safe and practicable solutions to help us make Elsenham crossing even safer,” says Jon Wiseman, Network Rail Anglia route director. “We have taken a number of measures to make the crossing at Elsenham even safer. We have arranged for a greater British Transport Police presence at the crossing, and we will be fitting an ‘another-train-coming’ voice alarm.”
Wiseman also says recommendations will also follow for 13 other crossings similar to Elsenham.
But Wiseman and the company still insist these new measures only make an already safe Elsenham, ‘even safer’.
4. Risk Assessment failures
In 2006, the RAIB also begins to unravel a knot of failings in Network Rail’s risk assessments of Elsenham.
Of the December 2005 re-assessment and high risk score of ‘47’, the RAIB says: ‘Network Rail’s scoring for Elsenham did not include any allowance for special local factors at Elsenham such as the number of school aged users.’ The implication is the risk score should have been higher.
The RAIB also describes Network Rail’s risk assessment of Elsenham, scored at ‘28’ – conducted in April 2005 – as ‘substantially flawed’.
6. Ticket machine installation
At some time before December 2006, TOC ‘one’ Railway installs a ticket machine on Elsenham’s Down platform.
Video surveillance also monitors the crossing.
7. ‘Don’t Run the Risk’ campaign
At this time, Network Rail promotes ‘Don’t Run the Risk’, a public safety campaign to get pedestrians and drivers to safely use level crossings.
The families of Olivia Bazlinton and Charlotte Thompson welcome Network Rail’s broader safety campaign. As early as September 2006, Tina Hughes, Olivia’s mother, has helped officials from Network Rail, British Transport Police and ‘one’ Railway to hand out level crossing safety leaflets at Elsenham.
Network Rail include Hughes in a 4 September press release, quoting Hughes as saying: “We support Network Rail’s efforts to raise awareness about the level crossing at Elsenham and encourage safe and proper use among the many people who use the station to commute to school and work.”
Route director Jon Wiseman adds: “We thank Tina Hughes for her involvement in the campaign and would urge all local people to pick up a leaflet to ensure they use the crossing safely and correctly.”
7. RAIB publication
The RAIB publishes its authoritative report in December 2006.
On the issue of responsibility for the Elsenham tragedy, the RAIB states: ‘Pedestrian users have an obligation to take care and to follow any instructions. Crossing providers have an obligation to take reasonably practicable steps to reduce the risk that users will be harmed as a consequence of an error or lapse.’
The RAIB reflects on the absence of action taken after the 1989 Elsenham fatality. An investigation after that accident found the elderly woman had crossed from the Downside to the Upside whist a red light showed.
Later, HMRI had recommended the addition of a two-tone yodel alarm to warn crossing users of the approach of a second train. These two-tone alarms had been installed on some vehicular level crossings. But British Rail, then responsible for the UK rail network, failed to act on this recommendation for Elsenham. The RAIB says it remains unclear why no action was taken in the months and years after the 1989 fatality.
Many regular users frequently cross as the red light shows and the single-tone yodel sounds, according to ‘occurrence books’ studied by investigators after the December 2005 fatalities. The RAIB notes entries are not entered into the Safety Management Information System out of which safety measures can arise.
8. ORR – the Regulator
The Office of Rail Regulation, established by the Railways and Transport Safety Act 2003, is the independent safety and economic regulator for Britain’s railways.
One of the Office of Rail Regulation’s main tasks is to secure the safe operation of the UK’s railways and, as the ORR itself states: ‘…to protect both those working on the system and members of the public from health and safety risks arising from the railways’.
To achieve this task, the Office of Rail Regulation (ORR) regulates Network Rail’s role as steward of the national rail system, including Network Rail’s funding. But questions arise – well into 2013 – over a possible conflict of interest between the ORR’s duty to prudently regulate Network Rail’s finances and its other duty to ensure the company operates a safe railway – particularly in political climates where ‘austerity’ economics and expenditure cuts dominate.
Questions are also asked why the ORR does not officially measure the performance of Network Rail’s board of directors in relation to safety.
Specifically, in relation to level crossings, Ian Prosser, ORR director of railway safety, says: “ORR’s vision is to see zero industry-caused fatalities amongst passengers, public and workforce. UK level crossings are ranked as the safest in Europe but the goal is continuous improvement.”
The ORR also investigates the Elsenham tragedy during 2005 and 2006 – and closes that investigation in May 2007.
9. In the line
An internal Network Rail reorganisation in 2006, known as ‘safety in the line’, leads to the creation of a new team on the Anglia Route. This consists of six people including an Operations Risk Adviser, two Level Crossing Risk Control Coordinators, a signalling risk control co-ordinator and two signalling inspectors.
Network Rail also introduces the All Level Crossing Risk Model (ALCRM) as part of level crossing risk assessments in 2007. The ALCRM enhances assessments by focusing on the number and type of crossing users and the number of trains. It also takes into account poor sight lines, and glare from sunlight at certain times of day.
If an individual uses a level crossing frequently – 500 times per year – ALCRM estimates their risk of death, and rates it by a letter on a letter scale ranging from ‘A (High) to M (Low)’.
ALCRM also estimates the collective risk generated by the crossing, taking into account the overall risk of death and injury for crossing users, train crew and passengers. Collective risk is rated using a number scale ranging from ‘1 (High) to 13 (Low)’.
Cost benefit analyses are carried out on the basis of the ALCRM risk model to determine the ‘reasonable practicability’ of risk reduction measures – ranging from new warning signs and increasing the volume of audible alarms to installing a footbridge and even closing a crossing.
The Level Crossing Risk Management Toolkit, produced by the Rail Safety and Standards Board, sets out these mitigation measures.
In 2007, Network Rail establishes a new web of arrangements.
The Operations Risk Advisor reviews risk mitigation measures recommended by Level Crossing Risk Control Coordinators. The ORA further reviews proposals with the Route General Manager, the officeholder responsible for reducing level crossing risk, ‘as far as is reasonably practicable’, in each region. Finally, if the measures are deemed reasonable, a Route Enforcement Manager directs their implementation.
PART 8: Inquest 1. Coroner’s Inquest 2. Verdict 3. Top Gear and ‘Don’t Run Risk’
1. Coroner’s Inquest
People go to an inquest to discover the circumstances of a death.
They also expect to gain insights into who is responsible and to get answers to questions about duty of care and possible negligence.
In January 2007, Essex Coroner Caroline Beasley-Murray presides over a four-day inquest at Chelmsford County Hall into the deaths of Charlotte Thompson and Olivia Bazlinton on 3 December 2005.
The inquest highlights certain inadequacies within the UK coroner inquest process.
Publicly-funded barristers, backed by solicitors, represent Network Rail and the train operating companies involved. Public relations officers hover.
Only a British Transport Police welfare and family liaison officer supports the girls’ families. Legal aid is not available at inquests for victims’ families.
The families attend a meeting before the inquest where Network Rail and National Express solicitors make pre-inquest representations to the Coroner. Network Rail solicitors say evidence from a risk assessment expert ought to be excluded from the inquest. They reportedly argue that lay jury members – as ordinary members of the public – would not be able to understand the complexities of risk assessments.
The Coroner agrees to exclude elements of risk assessment evidence from the inquest. This decision excludes a paper by Iain Ferguson of the Health and Safety Laboratory, a research agency of the government’s Heath and Safety Executive. Ferguson has concluded Network Rail’s management of risk assessments is flawed – and both the April and December 2005 assessments underestimated the risks at Elsenham.
‘I would conclude that Network Rail does not provide the basis of a suitable and sufficient risk assessment,’ states Ferguson in his report.
But Ferguson’s report is excluded from the inquest.
The inquest does hear some risk assessment evidence from RAIB principal inspector Simon French. He tells the jury that Network Rail’s April 2005 risk assessment used an unsophisticated ‘interim’ method.
Simon Hall was a passenger on the Cambridge-bound train on 5 December 2005. “I had an immediate impression of two bright, smiling shiny people,” says Hall, giving evidence at the inquest about Olivia and Charlotte.
Crossing keeper Joe Carriman, giving evidence, claims he was standing outside his cabin on the Up platform, close to the girls. “The express was so close. You could hardly see it until it was right on top of you,” says Carriman. “I didn’t think they would go across. I couldn’t believe it. There was no time for me to issue a warning.”
Detective Chief Inspector Michael Southerton of British Transport Police tells the inquest that after the tragedy people still cross as the red lights show and the yodel alarm sounds.
Ten members of the inquest jury visit the level crossing. Network Rail reportedly insist on a reduced line speed and require jury members wear high-visibility tabards – an irony not lost on the families of Olivia and Charlotte.
The coroner directs the jury to reach a verdict of ‘accidental death’.
The families feel disadvantaged and unfairly treated by the inquest. “There was no support for us through the inquest in terms of legal advice,” recalls Tina Hughes, Olivia’s mother. “We were not allowed legal aid, and we could not afford to employ a barrister or a solicitor for four days to support us.”
“This is a whole litany of incompetence,” says Reg Thompson, Charlotte’s father. “And there is the question of negligence.”
3. Top Gear and ‘Don’t Run the Risk’
Around this time, Network Rail is promoting its ‘Don’t run the risk’, a multi-million pound TV and radio level crossing safety campaign.
In one instance, BBC Top Gear presenter Jeremy Clarkson presides over a staged event when a remote-controlled 107-tonne diesel locomotive crashes at 70 mph into a people carrier parked on a level crossing.
Network Rail’s Iain Coucher says: “Though light-hearted in tone, the message is serious…Level crossings are safe if used correctly so don’t misuse them.”
PART 9: Grayrigg 1. Switches and Crossings 2. Contrite apology 3. Bonuses 4. Elsenham footbridge installed 5. Engineering overruns 6. New executive board members 7. Civil cases 8. ‘Misuse’ mantra 9. David Higgins 10. Coucher to resign 11. All Level Crossings Risk Model 12. New chief executive 13. Civil cases settlement
1. Switches and crossings
During 2007-08, the Elsenham tragedy begins to fade from public view, as rail safety concerns turn to a train derailment tragedy – and then safety is overshadowed by engineering overruns.
Many of the UK railway’s tracks feature ‘Switches and Crossings’ (S&C). These connections allow trains to cross between rail lines. Points operate these switches and crossings. Some points are over 35-years-old and possibly subjected to forces beyond the capability of their original design.
On 23 February 2007, Margaret Masson, aged 84, is killed and 28 people are seriously injured when a high-speed tilting Class 390 Virgin Pendolino London-Glasgow train, travelling at 94mph on the West Coast Main Line, derails and throws all eight carriages down an embankment at Grayrigg in Cumbria. Five carriages flip onto their sides.
The catastrophic derailment occurs as the train goes through a set of facing points, known as at Lambrigg 2B, near Grayrigg. The 2B points enable a train to switch from one set of rails to another. But the mechanisms operating this switching are in an unsafe state.
The points are unsafe due to an undetected failure of a third permanent way stretcher bar and its joint, and possibly some aspects of the deterioration of a second permanent way stretcher bar.
Fixed stretcher bars hold switch rails at a set distance apart. When one switch rail closes during the operation of the points the other switch rail opens. This creates and maintains a gap for the wheel flange to pass through.
This stretcher bar system failure at Lambrigg results in a loss of restraint on the left-hand switch rail, one of the two rails that switches trains from one set of rails to another. These failures allow the left-hand switch rail to move, now without command by the signalling system, to a position close to the stock rail.
This rail is now in the path of the approaching Glasgow-bound train. The wheels of the first and second carriages strike the tip of the now loose rail, derail, and cause the other carriages to also derail.
The points may have deteriorated significantly in the eleven days prior to the tragedy.
An 18 February inspection should have detected the deterioration.
But a supervisor forgot to extend his visual inspection to include the Lambrigg 2B points.
2. Contrite apology
In an immediately contrite response, chief executive John Armitt says: “Network Rail is devastated to conclude that the condition of the set of points at Grayrigg caused this terrible accident…We would like to apologise to all the people affected by the failure of the infrastructure.
“We now need to understand how the points came to be in this condition – and we will leave no stone unturned in our search for the facts behind this derailment. We will continue to co-operate fully with the investigators as they work towards more detailed conclusions.”
Armitt concludes: “We again extend our sympathies to the family and friends of Margaret Masson, who died as a result of the incident, and to those who were injured and shaken.”
Margaret Masson’s death in February 2007 is the first highly publicised – ‘front-page news’ – fatality on the UK’s railways since the Elsenham fatalities in December 2005.
The Grayrigg derailment is the first major train disaster since seven people were killed at Ufton Nervet in November 2004. It is also the first fatality to be caused by a catastrophic failure of the railway’s maintenance regime since seven died at Potters Bar in May 2002.
In May 2007, Armitt and Coucher, along with two other Network Rail executive directors – finance director Ron Henderson and infrastructure director Peter Henderson – decide to defer their annual bonuses until the causes of Grayrigg are determined.
Bonuses are set by the company’s remuneration committee, aligned to both the performance objectives of the company and the demands of passengers – chiefly, the extent that Network Rail complies with its licence from the ORR to provide a railway where trains operate punctually. The committee takes into account train delays attributed to rail infrastructure failings.
Armitt’s deferred annual bonus is £88,740. Another 119 people see their bonuses deferred, including the Director of Maintenance and staff directly involved in track maintenance at Grayrigg. The average annual deferred bonus for employees who physically work on the tracks is £400.
The RAIB says Network Rail has not systematically observed the performance of S&Cs “at appropriate individual component level”.
The RAIB concludes: “This incomplete understanding of the performance of S&C with non-adjustable stretcher bars, and the relationships between its design, usage, loadings, inspection and maintenance, led Network Rail to consider that the risk associated with the design was low and was being adequately controlled. This also resulted in an absence of clear and properly briefed standards for the setting up and adjustment of S&C.”
The Lambrigg points are removed and not replaced.
In September 2007, Coucher says: “Shortly after the tragedy at Grayrigg, we accepted responsibility for the derailment and apologised to everyone affected…Mistakes were made and there are important lessons for all of us at Network Rail…Travelling by train is the safest form of transport – what we must do now is make it safer still.”
4. Elsenham footbridge installed
Earlier, in June 2007, Uttlesford District Council approves a Network Rail plan to build a pedestrian footbridge at Elsenham station – despite some local opposition.
‘With rail traffic due to increase in future years the construction of a footbridge along with a pedestrian gate locking system will help make the crossing safer,’ says Network Rail in July 2007.
In August 2007, the new pedestrian gate locking system and footbridge are installed. The footpath crossing gates are interlocked with the train signalling system. Trains do not approach and pass until both the road and footpath crossing gates are locked.
New notices inform passengers that the footpath crossing gates will be locked when the road gates are closed to allow trains to pass through. The footpath gates will be locked for as long as the road gates are closed.
The steel-frame, stepped footbridge costs £2m and is built by installing 34 mini piles – each 7 metres deep – to take the weight of the bridge, and to enable it to withstand a collision if struck by a derailed train.
CCTV is installed to monitor any erroneous crossing usage or deliberate misuse – and to support any enforcement action by British Transport Police.
Patrick Hallgate, now Anglia route director, talking about the footbridge, says: “We’re pleased to offer a safe alternative to crossing the railway.”
The families of the two girls welcome the footbridge and the locking pedestrian gates as ways of safeguarding others against what happened to Olivia and Charlotte. But they also feel that Network Rail, to invoke an old phrase, ‘is locking the stable door after the horse has already bolted’.
A family statement says: “Even more annoying is Network Rail’s continued reference to the bridge and locked gates making the crossing even safer, implying that the crossing was already safe. The safety assessments proved the crossing had serious flaws; it is time Network Rail acknowledged that.”
5. Engineering overruns
Network Rail suffers further fierce public and political criticism throughout 2008. Three serious engineering overruns over the 2007-08 Christmas and New Year period upset the travel plans of thousands of passengers, and cost the company millions of pounds in lost revenue and fines.
Track modernisation at sites like Rugby on the West Coast Main Line ought to finish by December 30 but take an extra four days. Network Rail is fined a record £14m by the ORR – a move itself criticised as ‘robbing Peter to pay Paul’, a reference to using taxpayers’ money to fine a company directly funded by taxpayers.
Coucher faces criticism from Members of Parliament on the House of Commons Transport Select Committee, chaired by Gwyneth Dunwoody MP. Coucher tries to set the failures in context, as only three overruns out of 5,000 engineering projects in an annual £4bn programme.
But, in a stinging select committee report in July 2008, MPs state: ‘The engineering overruns over New Year were quite simply unacceptable. Much excellent work is done by a large workforce of good and dedicated staff at Network Rail, but the lack of clear procedures, consistency, communication and management controls combine to undermine all these undoubted achievements.’
Bonus payments arise again. The company announces staff will receive bonuses totalling £55m for the year 2007-08. Although bonuses are distributed widely amongst Network Rail’s 34,000 staff, chief executive Iain Coucher stands to receive more than £305,000.
Coucher and colleagues tells MPs punctuality has majorly improved and they point also to an after-tax profit of £1.2bn. The figures include the record £14m penalty imposed by the ORR.
In their report, MPs state: ‘It is quite extraordinary for Network Rail to reward its senior managers with huge financial bonuses in a year where passengers have been humiliated and inconvenienced by three separate major engineering fiascos, where an entire catalogue of management failings has been laid bare for all to see (Grayrigg), and where a record fine has been imposed for a breach of the Network licence.’
The MPs conclude Network Rail’s board of members are ‘not a body worth having’ and call for a ‘smaller, independent group’ to whom the Board (of directors) can be truly answerable for operational matters.
Coucher responds: “We are disappointed by the comments in the Transport Select Committee report which do not reflect the pivotal role Network Rail has played in turning around the railway from the mess inherited from Railtrack.”
6. New executive board members
In September 2008, Network Rail appoints three new executive directors to its executive board: infrastructure investment director Simon Kirby, planning and regulation director Paul Plummer, and Robin Gisby, as operations and customer service director.
Gisby, with an Engineering Science degree and MBA, spent several years in the UK and overseas in engineering and operation roles. He joined Railtrack in 1997 and became the company’s director of network development and freight. Gisby is director of Network Rail’s eastern and southern regions before becoming operations and customer services director in May 2004.
7. Civil cases
In late 2008, Tina Hughes, Olivia’s mother, launches a civil case against Network Rail on behalf of herself and Olivia’s older sister, Stephanie Bazlinton.
Reg Thompson launches a similar case on behalf of the Thompson family – Charlotte’s mother Hilary and two brothers, Robbie and Harry.
Tina Hughes initiates her legal action to prove Network Rail’s negligence. If successful, Hughes hopes the ORR, as regulator, will insist Network Rail take action to change the way it manages risk at level crossings.
8. ‘Misuse’ mantra
In 2008, 15 people lose their lives at level crossings in Britain. But Network Rail says deaths at Britain’s 6,500 level crossings are “low by international standards”.
Over 600 people die at level crossings across Europe each year – with more than 3,400 incidents of ‘misuse’. Germany, France, the Netherlands and Spain all have more people killed at level crossings than Britain in 2008.
In summer 2009, Network Rail revitalises its ‘Don’t Run the Risk’ level crossing safety campaign with an added slogan ‘Would it kill you to wait?’
“Level crossings are safe if used correctly, says Martin Gallagher, the company’s head of community safety. “But time and time again, we see people risking their lives by jumping the gates, swerving around barriers and ignoring warning signs.”
Network Rail says 55 days of delays to trains and passengers were caused by level crossing ‘misuse’, costing Network Rail around £1.8m in penalty payments to train operating companies.
In September 2009, Network Rail shows images, captured in May 2009, of a woman dashing over a footpath crossing whilst pushing a baby in a pram at Wareham in Dorset. A red light shows as a train bears down on them.
Between January and September 2009, 12 people are killed at UK level crossings. Nine collisions occur between motor vehicles and trains. 189 pedestrians narrowly avoid being hit by a train, compared to 280 during the whole of 2008.
Network Rail also focuses on The Highway Code provision 296 that states: ‘User-operated gates or barriers. Some crossings have ‘Stop; signs and small red and green lights. You MUST NOT cross when the red light is showing, only cross when the green light is on.’
By the end of 2009, 13 people have died at level crossings. Most incidents involve collisions between trains and motor vehicles on level crossings. Iain Coucher says: “Thousands of pedestrians also use level crossings every day, and we know that many misuse them, putting themselves at risk. I would urge everyone to observe the warnings signs and lights and use crossings safely and correctly.”
9. David Higgins
In February 2010, David Higgins is appointed to the Network Rail board as a new non-executive director. At this time, Higgins is the highly regarded chief executive of the Olympic Delivery Authority, the body preparing the stadiums, venue and infrastructure for the forthcoming London 2012 Olympic Games.
Higgins is a former chief executive of English Partnerships, the regeneration agency for England, a post he held between 2003-05. Prior to that, Higgins was group chief executive of Lend Lease, the global construction group and property developer.
Throughout the first half of 201o, Network Rail management seems preoccupied with threatened strike action over its plans to reduce staff that maintain the UK’s rail tracks, signalling systems and rail power supplies. A High Court injunction stops a signallers’ strike. Maintenance staff abandon a planned strike.
Network Rail employs about 18,000 rail maintenance staff by April 2010.
10. Coucher to resign
Iain Coucher tells Network Rail’s board in June 2010 that he intends to step down after three years as chief executive, and eight years in total with the company.
Coucher reportedly received bonuses of up to £641,000 in 2009/10 on top of his basic salary of £613,000. On termination of his contract, he will receive a ‘compensation package’ of £1.075m. This includes an incentive payment of £370,000. He leaves with an accrued occupational pension of over £186,000.
Transport Secretary Phillip Hammond asks if it is “appropriate” for Network Rail executives to receive such large bonuses when much of the population is enduring ‘austerity’. The ‘austerity’ is imposed by the government, in its response to the financial and economic ‘meltdown’ of 2008-09.
In June 2010, Network Rail takes part in an International Level Crossing Day of Action, where participating countries stage ‘level crossing awareness’ events, coordinated by the International Union of Railways.
Network Rail and British Transport Police hold awareness events at level crossings at:
- Ardrossan Harbour/Town
- Beverley Station
- Bloxwich, Walsall
- Blythe Bridge, Staffordshire
- Croxton (Cambridgeshire)
- Enfield Lock
- Llanelli East
- Mitcham Eastfields
- Red Cow (Exeter)
Network Rail stresses the United States of America scores the highest number of level crossing deaths with 248 fatalities in 2009, compared to 13 in Britain.
11. All Level Crossings Risk Model
Network Rail recalibrates the All Level Crossings Risk Model in 2010 to align it with version 6 of the RSSB’s safety risk model. The company also corrects a software issue.
After 2010, Operations Risk Control Coordinators are tasked to carry out cost benefit analyses of risk reduction measures, still using the RSSB’s Level Crossing Risk Management Toolkit.
The newly calibrated ALCRM calculates the benefit-cost ratio for each proposed mitigation, and considers the capital outlay, recurring costs, and benefits. The cost of the proposed measure is compared with the long-term effectiveness of the risk reduction.
Benefits are split into safety, based on a predicted reduction in deaths and injuries, and finance, such as reduced annual maintenance costs.
12. New chief executive
In September 2010, Australian-born David Higgins is announced as the new chief executive of Network Rail. Higgins, still with the Olympic Delivery Authority, will take up his new role on 1 February 2011.
Asset management director Peter Henderson will hold the fort until Higgins arrives.
“Network Rail is one of the most important companies in the UK – and therefore a challenge I could not turn down,” says Higgins.
Higgins doesn’t know it yet; but that challenge is about to become even greater.
13. Civil cases settlement
In November 2010, almost five years after the tragedy, Network Rail does not submit evidence to defend itself against the civil cases brought by certain members of Olivia and Charlotte’s families.
The company agrees an out-of-court settlement.
Network Rail reportedly “demands 20 per cent of the blame is attributed to the girls”, meaning the families face a 10% reduction for ‘contributory negligence’.
The maximum settlement payable for each fatality is £10,000 plus expenses for funerals.
Network Rail and the families settles the cases – allowing the company’s board to heave a corporate sigh of relief.
It turns out to be a premature exhalation.
PART 10: Hudd and Hill 1. A tale of two documents 2. Hill risk assessment 3. Part B 4. “Furious” reaction 5. Hill comment 6. Higgins new chief executive 7. The ‘Hudd Memo’ 8. “Those bastards knew” 9. Hudd Memo previously undisclosed 10. Maryanne Rosse
Hudd and Hill
1. A tale of two documents
Tom Condon, a former industrial correspondent for national newspapers, works for the railway staff trade union, the Transport Salaried Staffs’ Association.
Condon tells Chris Bazlinton, Olivia’s father, about the possible existence of two crucial and hitherto undisclosed documents, seen neither by the Coroner nor by the official inquiries. Bazlinton tells Condon he hasn’t seen either document.
In early 2011, these documents will place Network Rail under renewed pressure over Elsenham, just as David Higgins joins as chief executive.
One document is traced. Solicitors acting for Tina Hughes, Olivia’s mother, return a set of the papers used in the civil case. Hughes says she glanced through them as she was about to place them in an attic. But she noticed a 2002 risk assessment of Elsenham that she had not seen before. It later transpires that the coroner, RAIB and HMRI had also not seen this risk assessment.
Later, a second and previously unseen document ‘emerges’.
Both documents contain fresh and bitterly cruel twists for the families of Olivia Bazlinton and Charlotte Thompson.
2. Hill risk assessment
The first document to ‘surface’ is an Elsenham risk assessment – prepared for Railtrack by Trevor Hill on 23 May 2002 – over three and a half years before the December 2005 disaster.
In May 2002, Hill, a Level Crossings Risk Manager, scores Elsenham level crossing only as ‘1’ – meaning the likelihood of anyone being hit by a second train is ‘unlikely’. His risk assessment does not take into account 32 instances of erroneous crossing usage in the months before May 2002. Hill says the crossing’s risks controls, notably the miniature warning lights, are adequate.
Curiously, however, Hill’s assessment includes a Part B.
This Part B is curious and important for three reasons. Firstly, there is no titled Part A in Hill’s risk assessment. Had there been a Part A questions might have been asked about the existence of other parts to the assessment.
Secondly, and more significantly, Hill suggests in this Part B that locking the pedestrian gates at Elsenham ought to be considered.
Thirdly, Part B was not mentioned in the coroner’s inquest and has not been seen by the RAIB investigators or by the girls’ families.
3. Part B
Hill’s Part B of the risk assessment record, states: ‘However, consideration should be given to the practicality of incorporating the Wicket Gates into the interlocking of Elsenham crossing controls and effectively lock them closed when trains are approaching.’
Hill signs the assessment but Level Crossing Manager W.J. Hudd does not authorise the document until 1 October 2003 – by which time Network Rail has taken over formal responsibility from Railtrack for the UK’s rail infrastructure.
4. “Furious” reaction
The shocked families say Network Rail could have acted on Hill’s Part B 2002 recommendation to install locking gates at Elsenham.
Had the company done so, their young, much-loved and loving daughters would not have been able to step onto the crossing in December 2005.
“We were absolutely furious,” recalls Bazlinton. “Network Rail should’ve given the coroner and the Rail Accident Investigation Branch the whole document.”
Network Rail denies withholding the risk assessment, including Part B. An initial statement claims it would have supplied any documents requested by the coroner.
The company also claims its legal team and solicitors had given Part B of the risk assessment to the Thompson family on 9 May 2006 – and then claims to have given the full risk assessment to solicitors representing both of the girls’ families.
The family members vigorously challenge this claim. Reg Thompson spoke to Cobbetts, a firm of solicitors, a few times on the phone in the Spring of 2006 but never appointed them. He never saw any papers Cobbetts may have received.
Olivia’s parents say they were never approached. They were not even represented by solicitors at that time.
5. Hill comment
Trevor Hill’s Part B ‘emerges’ during the civil case brought by the families against Network Rail. The existence of Part B is revealed to the general public by The Times newspaper on 12 February 2011.
Trevor Hill refuses to comment about his risk assessment. W.J. Hudd says he cannot recall Elsenham before the tragedy, as he managed over 1,000 level crossings in his East Anglia region.
Neither Hudd nor Hill gave evidence at the coroner’s inquest.
Iain Coucher, Higgins’ predecessor from 2007 until 2011, tells reporter Phillip Pank at The Times: “Elsenham was a tragic accident which I will never forget.
“As deputy chief executive responsible for day-to-day operations at the time of the incident and the subsequent inquest, I was not involved in any way in decisions relating to the provision of information to various bodies. This was handled by Network Rail’s legal services department.
“Furthermore, I was never involved in decisions relating to risk assessments. This is, rightly, always done by local, specialist managers who understand the wider context of level crossing risk at a specific location. That said, in my time at the company I always encouraged an atmosphere of openness and a culture of safety.”
Unhappy ORR officials describe Hill’s May 2002 record of a risk assessment as ‘a key document which it had not seen previously…and which was not included in a bundle of documents provided to meet the inspector’s request immediately after the accident’.
Network Rail also reportedly did not send Hill’s Part B to the RAIB or to coroner Beasley-Murray.
Ian Prosser, the ORR’s director of railway safety, asks ORR inspectors to see if the document affects the outcome of its original investigation that closed in 2007.
The ORR reopens its previously closed investigation.
“We were extremely disappointed to learn of the existence of a vital document not previously disclosed to our investigation,” says Prosser.
Network Rail will soon disappoint the ORR again – and anger the girls’ families even further.
6. Higgins starts as new chief executive
David Higgins takes over from Iain Coucher as chief executive on 1 February 2011 and says: “I want people to associate these words with Network Rail: open, transparent, accountable, responsive.”
But Higgins inherits Elsenham from Coucher. Higgins barely has time to warm his office chair as the new boss before The Times splashes its exclusive that Network Rail had ‘distributed’ the May 2002 risk assessment but had ‘withheld’ Part B.
Higgins orders the withdrawal of the original statement denying Network Rail had withheld Part B, and that it had given the full document to any solicitors the company claimed were representing the families.
Higgins also reportedly is unhappy with members of the company press and public relations division. A press statement states: ‘The families have endured many years of private grief. Network Rail urges the media to maintain its consideration in this respect.’
The families say they were never asked about this statement and demand Network Rail withdraws it. They see it as Network Rail PR officials trying to stem media interest in the Hill document revelations. Higgins reportedly demands he must clear all Elsenham statements before they are issued.
Higgins agrees to put together a list of all relevant documents. Higgins hands this list to the families at a meeting on 4 March 2011. The families agree the Hill document will not be published until after the ORR has completed its re-opened investigation.
But Trevor Hill’s Part B of the May 2002 risk assessment is not included when Higgins meets the girls’ families. Higgins hands the document to the families only after they make him aware it is missing.
TSSA rail union general secretary Gerry Doherty calls on Network Rail’s ‘double your salary’ bonus scheme to be cancelled after the ORR announces it has re-opened its inquiry into Elsenham. Doherty also refers to an RSSB report into 40% under-reporting of accidents by Network Rail because of a ‘culture of fear and bullying among middle managers’.
“We would like to see these safety questions being addressed seriously before Mr Higgins starts talking about paying himself huge bonuses of £600,000 a year like his little lamented predecessor Iain Coucher,” says Doherty.
7. The ‘Hudd memo’
Another indication of something awry inside Network Rail emerges later on in March 2011 in the shape of the second document.
John Hudd, a Level Crossings Standards Manager, writes a Railtrack memorandum on 4 May 2001 – over four and a half years before the tragedy.
Hudd predicts fatalities at Elsenham.
Hudd sends his memorandum to Jo Green, Route Production Manager.
Hudd visits Elsenham and then writes to Green on 4 May 2001, stating: ‘I visited Elsenham yesterday and spent some time with the crossing keeper and observing the operation there.
‘I have quite serious reservations about the arrangements which are in place for pedestrians. Although Miniature Warning Lights are provided (which operate quite independently of the crossing keeper and main gates) the associated wicket gates are totally free (as they are bound to be with MWLs). Pedestrians therefore can, and, apparently quite often do, cross when the lights are red.
‘The reason is not difficult to understand, the paper shop is on the downside and the booking office (and only ticket machine) are on the upside with the crossing in between. There is therefore a lot of to-ing and fro-ing. People from the car park (upside) get their paper (downside) and eventually hope to catch a train from the up platform.
‘Similarly passengers from the village (downside) may require a ticket to travel to, say Cambridge, and again have to cross over twice. The bulk of London commuters probably walk to the station or are dropped off on the downside and therefore use the crossing only in the morning.’
Hudd’s memorandum to Green continues: ‘The platforms are staggered, so if you need to catch a train from the far platform when one has just run over the crossing on the nearest track (and possibly stopped , then the temptation to cross over behind the train (even though the lights may still be red possibly for another train approaching) are, to many, irresistible. The sighting to trains in either direction is very poor and the risk of disaster are real. (sic)
‘The combination of free pedestrian gates adjacent to locked vehicular gates with a crossing keeper on hand is not very comprehensible to the layman (or me!) What makes the whole thing I believe undesirably risky is the large numbers of users (which includes a lot of schoolchildren).’
Hudd further tells Green: ‘The problem is, of course, a lot easier to describe than justify a solution. To merely fit locks on the wickets and work them in association with the main gates would create many more delays to passengers, missed trains and aggravation for the crossing keeper. I thin a footbridge or subway would be highly desirable to remove most of the objections that this would generate. A ticket machine on the down platform would also be helpful in reducing the number of pedestrian crossings’
Hudd then asks Green: ‘Do you think it worthwhile undertaking discussions with WAGN (West Anglian Great Northern train operating company) with regards to station access arrangements in the first instance?
Level Crossing Standards Manager’
Hudd’s footbridge recommendation is not implemented until 2007.
8. “Those bastards knew”
“I felt absolutely sick when I read the Hudd memo,” recalls Chris Bazlinton.
Tina Hughes, Olivia’s mother, who has been helping Network Rail improve level crossing safety since the fatalities, is stunned and then incensed. “I fell into my chair and could not speak for half an hour,” says Hughes, recalling her reaction to finding out about the undisclosed document.
“I was appalled,” says Hughes. “Those bastards knew. They just knew.”
9. Hudd memo previously undisclosed
Higgins says he sees the Hudd document on the afternoon that ORR officials are about to go through Network Rail’s files. He learns the ‘Hudd memo’, as it becomes known, was never shown to the various investigators of the Elsenham fatalities – the RSSB, RAIB, ORR and the Coroner.
Chris Bazlinton writes to Transport Secretary Philip Hammond urging him to launch an inquiry into claims Network Rail deliberately withheld information from government-backed rail investigators and from coroner Beasley-Murray.
Another story in The Times publishes details of the Hudd memo on 11 May, 2011. Higgins appears before the House of Commons Public Accounts Committee to face questions from Members of Parliament about Network Rail’s finances and ‘efficiency’ plans.
At the end of the sitting, committee chair Margaret Hodge MP asks Higgins about reports in the press about the two documents. “There is a suggestion that two safety reports on the crossing were deliberately held back from the public and deliberately hidden from government investigators. Is that true?”
Higgins, sat alongside ORR chief executive Bill Emery, replies the matter is subject to an ORR review. “It’s probably not wise to talk until that finding comes out,” says Higgins. “The press report talks about a Railtrack memo, written in 2001, that emerges in 2006. When I saw it in the files I sent it to the regulators and to the family members.”
Higgins flounders somewhat afterwards and says the UK has the safest level crossings in Europe. Hodge is clearly unimpressed. Higgins then adds: “Elsenham was all about risk assessment – how the risk is assessed, who did it, their competencies, what happened to the information afterwards and what decisions were made…”
Higgins clarifies the May 2001 memo is only sent to the investigators in March 2011, more than six years after the tragedy. He adds: “If it was deliberately withheld – and it is material – that is something the ORR will determine. We shouldn’t prejudice that.”
Emery says the ORR hopes to finish its re-investigation soon – and will conclude whether the ORR changes its view on the “culpability of Network Rail for this particular event”.
Hodge, now clearly irritated, asks Emery to comment on whether the documents were deliberately withheld. Emery replies: “I don’t want to comment at this stage.”
10. Maryanne Rosse
The existence of both documents is first revealed in August 2010 by Maryanne Rosse, Network Rail’s operations risk control coordinator.
Rosse had sought help from the Transport Salaried Staffs’ Association in her dispute with her employer. Word reaches Tom Condon, who, in turn, informs Bazlinton. The phrase ‘smoking gun’ is used to describe the documents.
Rosse says she was responsible for sending all relevant documents to Network Rail’s legal department shortly after the December 2005 disaster. Rosse says she insisted Part B and the Hudd memo were included. She claims her computer was later wiped and so no evidence exists.
Rosse speaks to Rupert Lown, an ORR investigator, in March 2011. Rosse states: ‘I believe that contrary to their statements my employer (Network Rail) did not value or welcome my actions as a whistleblower and that as known as a whistleblower (sic) with trade union affiliations they were not comfortable with me being in my role with the Elsenham civil case or any re-investigations and that is why they behaved in the way they did towards me to bully me into leaving my post and keeping quiet.’
Later, Rosse becomes the centre of a highly publicised ‘whistleblower’ employment tribunal case. It involves allegations of falsified level crossing safety records.
For instance, in papers submitted to the London Central Employment Tribunal, Rosse alleges she had sent her bosses a list of 13 level crossings where inaccurate records were kept. Rosse claims one crossing near Ipswich had been classed as ‘compliant’ – despite an alleged near miss between a school bus and a fast train.
One allegation concerns Rosse signing a compromise agreement that bans her from publicly discussing any allegedly falsified records.
But the allegations are never heard in the tribunal. Her case is settled minutes before the tribunal is due to hear the first witness. In return, Rosse reportedly receives a £16,000 payment plus guaranteed employment for one year followed by a £40,000 severance payment.
Network Rail says: “Ms Rosse is a valued employee who did the right thing in revealing shortcomings within her department. As a result of her actions, significant changes and improvements have been made.”
But the company also says Ms Rosse’s claims are not supported by any evidence. Discrepancies are found at some crossings. One employee ‘loses their job’.
“I am disappointed if Network Rail has paid her to shut up because I want everything to come out,” says Tina Hughes, Olivia’s mother. “I thought things were changing but clearly they are not.”
PART 11: Who knew? 1. Who knew about Elsenham’s dangers? 2. Staff departures 3. Jo Green and Phillip Heath 4. Fund misuse allegations 5. Internal review at Network Rail 6. Potters Bar sentence 7. McNulty Report 8. Level crossing closures 9. Under-reporting of incidents
1. Who knew about Elsenham’s dangers?
Who though within Network Rail knew of the Hudd and Hill documents before they were disclosed?
Who else knew Elsenham station footpath crossing was considered highly dangerous by its own staff – especially Hudd?
Why did no action follow Hill’s recommendations and Hudd’s warnings?
Why did Hudd sign off Hill’s risk assessment and Part B but not mention the warnings he made in his own earlier memorandum?
Bazlinton pursues answers to these questions. “We can’t bring back Charlie and Olivia,” says Bazlinton. “But if you don’t name and bring to book people who are responsible then other people with responsibilities can be careless and feel they can get away too. We need to make sure those who have failed are named.”
Apart from Network Rail, Bazlinton includes the Rail Safety Standards Board, a company funded by the rail industry and government to collect and analyse data that can enhance safety research. The RSSB – not to be confused with the RAIB – carried out the first of several rail industry inquiries into Elsenham.
The RSSB admits in 2011 to having seen Hill’s Part B and reportedly discusses this section. However, for some reason, the RSSB deemed references to Part B unworthy of inclusion in its May 2006 inquiry report.
2. Staff departures
John Hudd retires in 2004, aged 56. He will be referred to as the man who signed off Hill’s 2002 risk assessment – and its potentially life-saving Part B document – but without referring to his own 2001 memo that, if also acted upon, might have saved the girls’ lives too.
Route manager Jon Wiseman leaves in 201o for a ‘career break’ – apparently to retrain as a cricket coach.
Following the May 2011 disclosure, two other departures from Network Rail are reported. Hazel Walker, responsible for Network Rail’s legal department, is said to be leaving soon for personal reasons. Safety and compliance director Julian Lindfield is reported to have recently left.
Human resources director Peter Bennett is said to be leaving in December 2011. Bennett is the subject of allegations of sex discrimination. He allegedly called an employee complaining of sex discrimination a “silly cow”.
3. Jo Green and Phillip Heath
Bazlinton’s attention focuses several Network Rail officials:
- Jo Green, a route production manager, who told the ORR she could not recall receiving the memo.
- Phillip Heath, general manager for West Anglia rail region at the time of the accident.
Bazlinton also highlights several officials hitherto in 2011 not yet questioned publicly by either appointed officials or elected representatives:
- Robin Gisby, managing director, network operations
- Richard Smith, solicitor, Network Rail
- John Wiseman, Anglia route director in 2005
4. ‘Fund misuse’ allegations
Meanwhile, Network Rail’s board of directors remains under scrutiny over pay, bonuses and perks. An ‘independent’ investigation, commissioned by Network Rail’s board – and conducted by Antony White QC, an asset tracing and employment law specialist – considers allegations of misuse and financial impropriety within Network Rail.
The rail union TSSA, and present and former Network Rail employees, had presented 12 allegations of misuse of public funds and serious financial impropriety. The allegations related to illicit payments to Iain Coucher and to financial impropriety or the misuse of compromise agreements and the behaviour of Human Resources director Peter Bennett.
Network Rail says 11 of the 12 allegations were found to be groundless or unfounded. On 24 May 2011, the company says: ‘The remaining allegation, about misuse of compromise agreements, had two components. On one of these components the report found no misuse of public funds.
‘On the second, there was no basis for allegations on three out of four cases put forward by the TSSA. However, in the fourth case the report concludes there was misuse.’
Network Rail says White’s 143-page report concludes ‘all of the allegations about illicit payments to Mr Coucher, and the use of offshore accounts, or huge amounts of cash, to make payments under compromise agreements to departing employees were groundless’.
It quotes White’s report as stating: ‘…it is hard to avoid the conclusion that the TSSA…introduced a series of increasingly serious allegations of financial impropriety against Mr Coucher for which it had no substantial evidence.’
Rick Haythornthwaite, chairman of Network Rail says: “His conclusions have confirmed earlier internal investigations’ findings that there was no case to answer regarding financial impropriety. However, in concluding that public funds were misused in with regard to one compromise agreement, Antony White is essentially expressing disagreement with the conclusions of the internal investigations undertaken in 2008.”
(Network Rail says White has posted a summary report on the website of Matrix Law, the chambers of which White is a member. The Matrix Law website makes a brief mention of the report. ‘A full copy of the Report has been provided to Network Rail and to the TSSA,’ says Matrix, which also says a link to a summary is available on its site).
5. Internal review at Network Rail
An internal review by former government transport adviser, Saratha Rajeswaran, writing about Network Rail’s governance, says: “Network Rail has been insulated from real-time economic and political concerns – leading to criticisms that it is arrogant or out-of-touch with the reality for the industry, passengers, the government and taxpayers.”
Rajeswaran, also a professional actress, does not advocate bolstering the powers of the company’s members over directors’ pay and bonuses, even though she warns bonuses will remain “contentious”.
Rajeswaran, at this time, is hired from public relations firm Portland Communications. She becomes David Higgins’ chief of staff after being a former strategy adviser to Network Rail’s board.
6. Potters Bar sentence
In the midst of the Elsenham revelations, the fallout over Coucher’s payoff and bonuses in 2011, Network Rail is sentenced and fined £3m for the fatalities at Potters Bar in 2002.
To those outside the rail industry, government and legal system, the May 2011 sentence typifies a bizarre and wasteful circularity of taxpayers’ money. Network Rail, a private yet not-for-profit taxpayer funded company, is sentenced and fined for the failings of its predecessor Railtrack, a private profit-seeking company also funded by taxpayers.
7. McNulty Report
The final report of a vaunted Rail Value for Money Study, launched in 2009 and jointly sponsored by the Department for Transport and the ORR, is published with much fanfare in May 2o11.
The study finds ten principal barriers impeding efficiency across the UK’s railways:
- Fragmentation of rail industry structures and interfaces
- The way in which major industry players operate
- Roles of government and industry
- Nature and effectiveness of incentives
- Fares structure
- Legal and contractual frameworks
- Supply chain management
- Insufficient emphasis on whole-system approaches
- Relationships and culture within the industry.
However, ‘efficiency’ and cutting costs drives the Study. Sir Roy McNulty, chair of the Study, says: “Achieving a 30% efficiency improvement by 2019 should be the target for the GB rail industry given the Study’s findings on the industry’s costs compared to European railways and other industries. A reduction of this magnitude is achievable, and is essential if passengers and taxpayers are to get the fair deal they deserve from the rail industry.”
The Study estimates that its recommended cost reductions could deliver savings between £700m and £1bn annually by 2019. “The rail industry has the opportunity for substantial further growth, building on the successes of the past fifteen years, but the licence to grow has to be earned by greater efficiency,” adds McNulty.
David Higgins, Network Rail chief executive, welcomes the report as a way of delivering a “sustainable railway” for Britain. “Sir Roy’s work gives the industry the direction it must take, a direction that has our full support,” says Higgins.
However, the rail unions criticise the report and highlight the incompatibility of the ORR functioning as both a safety regulator and as a body cutting Network Rail’s budget.
Margaret Hodge, chair of the Public Accounts Committee, reporting in July 2011, says the relationship between the ORR and Network Rail has become “too cosy” – although over Elsenham the ORR, particularly Ian Prosser, has pressed Network Rail to reveal information about its handling of Elsenham before and after the December 2005 disaster.
“We doubt whether the ORR can put effective pressure on Network Rail to improve its performance,” says Hodge. “The underperformance of Network Rail makes it all the more unacceptable that its senior managers should enjoy excessive bonus and performance payments.”
8. Level crossing closures
In May 2011, Higgins announces Network Rail will close 250 level crossings across the country to reduce the risk of fatalities by 25 per cent up to 2015.
Warning lights will be fitted at another 200 crossings, improved sighting times at 826 and spoken warnings at 129.
9. Under-reporting of incidents
Higgins receives a knighthood in the Queen’s Birthday Honours List in June 2011 for his ‘services to regeneration’, chiefly for his work on the Olympic Games infrastructure. But Higgins takes over Network Rail with the company facing intense scrutiny about excessive remuneration for its top executives, cuts to maintenance staff and a rising taxpayer-funded multi-billion pound debt.
Employees say redundancy fears sap morale amongst unit managers and maintenance and renewal staff. Fear of losing a job or risking being overlooked for promotion is often a reason why people do not report work-related incidents, accidents and even injuries.
A report by the RSSB, commissioned by Network Rail’s own board, states in January 2011 that staff and contractors have under-reported injuries since 2005 by up to 34%.
Summarising the report, Network Rail states: “There were several causes of under-reporting including misinterpretation of reporting requirements and fear felt by Network Rail staff and contractors if they reported accidents.”
At this time, Coucher also denies Network Rail defers £1 billion worth of vital signal and track upgrades in order to achieve cost reductions.
But some who work within Network Rail do not share Coucher’s outlook. The view of a Network Rail signaller and trainer, with ten years service, is typical. He tells the author just before Coucher departs and Higgins arrives: “We can’t raise any concerns because we’ll be cornered and left out of getting another job or being promoted. It’s not a good working environment.”
PART 12: “Spinning plates” 1. Grayrigg inquest 2. Reaction to Grayrigg inquest 3. Gipsy Lane 4. Criminal proceedings against Network Rail 5. Level crossing ‘champion’ 6. 500th level crossing closure 7. Enforcement vans 8. Guilty plea announcement 9. Families’ reaction to guilty plea 10. Tina Hughes’ reaction 11. Sentencing 12. Mitigation 13. Fine ‘implication’
1. Grayrigg inquest
In November 2011, Network Rail’s daily working culture is highlighted further by the two-week inquest into the death of Margaret Masson, 84, during the Grayrigg tragedy.
All eight passenger train carriages derailed after passing over a “degraded and unsafe” set of points.
The inquest jury hears evidence from Network Rail track supervisor David Lewis. Breaking down in tears, Lewis tells the jury and coroner Ian Smith how he forgot to inspect the points five days before the crash.
The jury learns an overworked Lewis led an under-staffed team, who often were not given enough time or even the right tools to conduct checks. The introduction of faster Virgin Pendolino trains also reduced track access time for inspections and patrols by 60%.
Lewis says he felt like he was under pressure, like a man “spinning plates on sticks”.
Lewis, no longer with Network Rail, says he emailed his bosses a year before the crash, telling them to “stop ducking the issue and sort this shambles out once and for all”.
The inquest hears how Lewis came into work on the day after he missed the check. Even though it was his day off, he was asked to give a presentation to his team on the theme of ‘Network Rail, a world-class company’.
Colleague Paul Wills, an assistant track manager, tells the inquest about a “bully-boy” management at Network Rail.
The jury hears about a number of shortcomings in Network Rail’s safety management arrangements that led to the accident. An RAIB report says Network Rail had an incomplete understanding of the performance of switches and crossings, no detailed assessment of the adequacy of their design or of inspection and maintenance arrangements.
The report adds: ‘Network Rail’s processes for performance management of S&C were not based on a thorough understanding of risk and control measures.’
The RAIB also states: ‘The track section manager worked extended hours in the weeks before the accident. The RAIB has no clear evidence whether this contributed to the omission of the basic visual inspection but is aware of other work which suggests there may be a link between long hours and performance.”
Coroner Ian Smith says it is a “tragic irony” that Lewis, who had tried to warn his managers about problems, is the employee who missed the points inspection.
Smith says he will issue a report under Rule 43 of the 1984 Coroners Rules to raise concerns with the regulator, notably the issue of track access for inspection workers.
The jury finds that the badly maintained points caused Masson’s death.
The ORR says: “ORR will now complete its investigation and will decide in accordance with prosecution protocol whether to bring criminal proceedings for health and safety offences.”
TSSA rail union Manuel Cortes goes further and says: “We have been warning Ministers and the media for some five years now about the bully boy style of management at Network Rail.
“It directly created the conditions which allowed this tragedy to unfold at Grayrigg. Cost cutting, staff under resourced and under pressure, all so the bosses could collect their huge annual bonuses.”
Network Rail’s Robin Gisby says: “Network Rail has not hidden from its responsibilities. The company quickly accepted that it was a fault with the infrastructure that caused the accident.
“We again apologise to Mrs Masson’s family.”
2. Reaction to Grayrigg inquest
Margaret Masson’s son, George Masson, 62, an engineer from Castlemilk, Glasgow, speaking outside the coroner’s court, says: “In my eyes it is negligence on Network Rail’s part, not him (David Lewis). The one that tried to make changes lost his job, his pension, he was not listened to from above.
“Before I knew anything about him I wanted to take his head off his shoulders. Now I totally respect him. He’s got my utmost respect for what he tried to do. It’s been swept under the carpet. They have not learned from Potters Bar. He’s the only one who has shown any remorse or integrity.”
Soyab Patel, a solicitor acting for Margaret Langley, Mrs Masson’s daughter, who was also badly injured in the derailment, says: “In Mrs Langley’s opinion these and other matters lie at the door of Network Rail.”
3. Gipsy Lane
Earlier, in August 2011, a pedestrian is killed by a train on the Gipsy Lane footpath crossing, near Needham Market in Suffolk. The train driver said he sounded a warning horn but the woman continued to cross.
The RAIB recommends that Network Rail makes sure level crossing data is collected accurately and consistently – and that it develops guidance on short-term mitigation measures at level crossings that have insufficient sighting or warning of trains.
The RAIB also recommends Network Rail enhances “the cost-benefit tool that is used to assess level crossing risk mitigation measures”.
5. Criminal proceedings against Network Rail
The non-disclosure of the two Elsenham documents triggers the ORR to review its previous position following its first investigation – namely not to prosecute Network Rail.
With Network Rail’s Hudd and Hill cats totally out of the bag, the ORR completes its re-opened investigation.
In November 2011, Ian Prosser announces: “After careful consideration and examination of Network Rail documents not previously seen by ORR, we have concluded there is enough evidence, and that it is in the public interest, to bring criminal proceedings against Network Rail for serious breaches of health and safety law which led to the deaths of Olivia Bazlinton and Charlotte Thompson at Elsenham station footpath crossing in December 2005.”
Network Rail will face two charges under the Management of Health and Safety at Work Regulations 1999 and one charge under the Health and Safety at Work etc. Act 1974. The ORR states: ‘These result from Network Rail’s failure to carry out proper assessments of the risks to the safety of members of the public using the footpath crossing or to have in place adequate arrangements to underpin these assessments.’
“Corporately, Network Rail are just shambolic,” says Tina Hughes. “Morally, they seem to have lost their way, because they think it is OK to do these things and then hide them.”
Hughes vows to continue to press Network Rail to make level crossings as safe as possible. She expresses faith that Higgins can “drag the company out of the fear and butt-covering that seemed to prevail”.
In November 2011, Hughes voices criticism of Network Rail’s lack of accountability. Writing in The Times on 25 November, Hughes states: “I fear that until Network Rail is made accountable it will continue to behave as it always has done. I believe some at Network Rail do not care if it is prosecuted. It is not excluded from bids for work, as many companies might be if they had to declare prosecutions; it is not in competition with anyone.
“It can defend the indefensible, as was the case with Elsenham, at the inquest, in the civil case and even this criminal case, because it appears to be accountable to no one.
“It has no shareholders to answer to. It is funded by the Treasury but is exempt from the Freedom of Information Act. Fines are just a financial transaction to return some of the money it is given to run the railway. Now if fines were taken from the bonus pot, that might make it sit up and take more notice.
“It has spent hundreds of thousands of pounds of public money on legal costs, when it had documentation that indicated that it was negligent. It has been allowed a privileged position for too long and it has made some believe that it is bulletproof.
“Sir David must sort out Network Rail’s attitude to legal issues. We are meant to believe that the evidence unearthed since February was not intentionally withheld during our civil case and therefore there was not contempt of court. If we find that people in their legal department have been anything other than scrupulously honest, I will complain to their professional bodies.”
Manuel Cortes, leader of the TSSA rail union, welcomes the ORR prosecution of Network Rail. “I sincerely hope that the criminal trial brings some level of comfort and closure to the families of both Liv and Charlie.
“They have suffered long years of anguish seeking truth and justice for their daughters and the full truth about just how lethally dangerous that level crossing really was. We now know that this anguish has been made worse by the knowledge that the two girls would still be alive today if NR had acted on either of the two hidden reports which only came to light this year.
“The parents will want answers at the trial over why no action was taken by senior NR managers over these two reports and why they were then not disclosed later at the full inquest.”
5. Level crossing ‘champion’
Sir David Higgins invites Tina Hughes to work alongside Network Rail to improve safety as a ‘level crossing user champion’. Hughes accepts and speaks to Network Rail staff about the importance of improving safety.
Hughes is well versed in corporate risk management culture via her own professional career. She retains a sceptical detachment, believing the role Higgins has created for her might be seen as “his way of managing an otherwise hostile stakeholder”.
But Hughes says the role enables her to “stay close to the crossing improvement programme”.
“I talk unashamedly to Network Rail staff about the trauma of Olivia’s death, not just for me and those who loved her but for everybody who was involved: the police, the train staff and the train driver,” says Hughes.
“It is important that they understand the impact of these types of deaths and that it is not just about the percentage points of a risk reduction that they are achieving.”
“I shall not rest until Network Rail engages in real change, so that other people do not have to suffer the pain that we have been forced to endure,” says Hughes in November 2011.
6. 500th level crossing closure
In December 2011, Network Rail closes its 500th level crossing since April 2009. A further 250 are earmarked for closure by April 2014.
Between April 2009 and September 2011, 13 pedestrians were killed at level crossings.
“In closing these 500 crossings we have removed the risk of a vehicle or a person being struck by a train,” says Robin Gisby. “While this is good progress, there is much more to be done. Closing a level crossing is not an easy process, and we often need the support of land owners, local authorities and users.”
2011 is also the year that the rail industry finally brings level crossings into the 21st Century. Level Crossings: A guide for managers, designers and operators (Railway Safety Publication 7, 2011), replaces the Railway Safety Principles and Guidance, part 2 section E, Guidance on level crossings, published by the HSE in 1996.
7. Enforcement vans
The Elsenham disaster of 2005 focuses Network Rail on improving level crossing safety. But the aforementioned fatalities – and several other accidents and near misses – show the company cannot afford complacency. Between January and April 2011, 77 pedestrians have near misses with trains and, according to Network Rail, “were lucky not to lose their lives”.
In January 2012, Network Rail says 2,452 people have been caught and charged with breaking the law at level crossings by three Network Rail/British Transport Police enforcement vans. Ten more vans will be operating to deter pedestrians and motorists from crossing after warning lights have begun flashing and alarms sounding.
“We’re confident that as the vans become more widely known and seen, that they will help bring down the number of level crossing incidents and make level crossings safer,” says Martin Gallagher, head of level crossings.
8. Guilty plea announcement
Network Rail tells Olivia and Charlotte’s families that the company will be pleading guilty to the two charges under the Management of Health and Safety at Work Regulations 1999, and also guilty to the one charge under the Health and Safety at Work etc. Act 1974.
The charges relate to:
– failure to carry out a suitable and sufficient risk assessment at the crossing
– failure to take steps to mitigate safety issues identified in a risk assessment
– failure to protect the safety of people using the railway.
Escaping the freezing rainy morning of Tuesday, 31 January 2012, the girls’ family members huddle inside Basildon Magistrates Court. They listen to evidence about Network Rail’s “protracted deficiencies”. District Judge John Woollard hears the company’s lawyers admit Network Rail failed to perform sufficient risk assessments and to install proper protective control measures.
The lawyers say Network Rail has a “complex obligation to analyse risk”. The company must “ensure preventative and protective measures are in place so crossing users are not exposed to risk”. But they admit Network Rail failed to make sure such arrangements were in place and so “failed to protect Olivia and Charlotte being exposed to risk at Elsenham”.
The Occurrence Books logged a high level of erroneous use of the crossing in the years before the tragedy. But Network Rail did not take steps to reduce risks.
One transcript of an Occurrence Book shows two other incidents; one on the Thursday and one on the day before the Saturday tragedy. The prosecution present evidence to Woollard of regular instances of other incidents going back to 2004.
Woollard rules the maximum combined fine of £30,000 that he can order is insufficient. He refers sentencing to a higher crown court. “The decision in relation to sentencing is because of the serious consequences of Network Rail’s failure to carry out its duties, and Network Rail’s financial standing,” rules Woollard. “Due to the serious nature of the matter it is right that it (sentencing) is moved.”
On the same day, David Higgins says: “Last year I apologised in person to the families of Olivia and Charlotte. Today, Network Rail repeats that apology. In this tragic case, Network Rail accepts that it was responsible for failings, and therefore we have pleaded guilty.
“Nothing we can say or do will lessen the pain felt by Olivia and Charlotte’s families,” adds Higgins. “But I have promised them that we are committed to making our railways as safe as possible. In recent years, we have reassessed all of our 6,500 level crossings and closed over 500. I accept that there is still a long way to go but we are making progress.”
9. Family reaction to guilty plea
Chris Bazlinton and Reg Thompson stand together outside the Basildon court in front of a pack of TV and radio reporters. Each father gives a personal reaction to the guilty plea.
“It proves they have lied to us over the years,” says Bazlinton. “Sir David Higgins has offered to meet us after the legal processes are over and we look forward to what he has to say.
“I believe there are many specific questions that are still unanswered and generally about why the revelations only emerged in the past twelve months, six years after the accident.
“I have no doubt Network Rail will change its procedures to ensure that action is taken when problems arise and to avoid a cover-up happening again. I think this should be transparent and open.
“I want to know how they are going to change the way they report on accidents and account for them. We shall be watching closely to make sure that the changes Network Rail promise to improve level crossing safety are carried out.
“Visions and plans are all very well but it is putting them in place that matters. I have confidence that David Higgins is the person to achieve change. His record of delivery at English Partnerships and at the Olympic Delivery Authority bodes well for the future.
“This is a significant day though. Network Rail have been found guilty of criminal behaviour. These charges today are criminal charges. I must stress this is not just technical.
“But any fine will be purely symbolic. There is no justice. Charlie and Liv can’t be brought back. The company has been brought to book but we’d like to see individuals also brought to book – or at least to be named. If you don’t name people who have failed, then other people with responsibilities will say ‘well we can get away with being careless or sloppy’. We need to make sure those who fail are named.
Reg Thompson says: “More than six years ago my daughter Charlie and her friend Liv were killed by an express train at Elsenham station in Essex. The horror of that day is always with us. The huge hole left in our lives by the absence of Charlie will never be filled.
“In the aftermath of the accident, Network Rail claimed that the girls had acted recklessly and that somehow their youthful exuberance led directly to their deaths – as if somehow being exuberant was a crime in itself. I never believed that Charlie and Liv were the architects of their own terrible end.
“It has taken six years to reveal the truth about what happened that day. Network Rail knew that Elsenham was a death trap. Five years before the accident, a safety report carried out at the station concluded Elsenham was a disaster waiting to happen. Over the coming years, further reports came to similar conclusions, and yet no action was taken.
“Indeed, an inspection carried out in the Spring of 2005 catastrophically found that Elsenham was well within existing safety parameters. This finding was later found to be substantially flawed.
“Network Rail knew about Elsenham and yet the company was happy to blame the deaths on the girls’ own actions. Without the commitment and energy of the ORR, and in particular Ian Prosser and Rupert Lown, today’s guilty plea would never have been possible. Network Rail’s actions prior to the deaths of our daughters can now be seen publicly as negligent and incompetent but also as supremely arrogant. But this gives me no satisfaction.
“There is no end. Charlie will not come home. Liv will not come home.
“The damage done to our families is irreparable.
“My only concern is that Network Rail puts the safety of its passengers at the top of its priorities.
“Only on Saturday another teenage girl, barely older than Charlie and Liv, was killed near Bishop’s Stortford, just three miles from Elsenham.
“Another terrible tragedy. Another daughter who won’t come home.”
10. Tina Hughes reaction
Tina Hughes, in The Times of 1 February, says: “I am pleased. I don’t want public money that could be spent on safety wasted on defending the indefensible. But what worries me is the conflict between Network Rail’s public position and its internal attitude…
“In my experience, staff understand the need for change. Since Sir David invited me to be a user champion for level crossings, I have spoken to several groups of staff about the devastating effect of this preventable ‘accident’ on our families. I have found them only too willing to listen…
“But it seems to me that some people in senior positions still don’t fully support the changes that must be made to the way that risks at level crossings are managed. Those who are champing at the bit to introduce new technologies and bring in improvements are thwarted by internal resistance. It amazes that is allowed to continue.
“I want to believe that Network Rail corporately deeply regrets the processes that led to Olivia and Charlie’s deaths. I wonder if what it really regrets is getting caught out. Network Rail must acknowledge that by non-disclosure it prolonged the anguish of everyone who knew Olivia and Charlie. We should not have had to fight for six years.
George and Scribbles finally get their day in court.
George, Olivia Bazlinton’s teddy bear, sports a faded pink scarf. Scribbles represents Charlotte Thompson.
It’s Thursday, 15 March 2012 and family members arrive at Chelmsford Crown Court. After pleading guilty to the three charges, Network Rail is about to be sentenced.
Charlotte Thompson’s mother, Hilary, walks into the courtroom. There is concern about her welfare; it’s the first time she has felt able to subject herself to court proceedings about her daughter’s death.
Hilary, clutching Scribbles greets Tina Hughes, Olivia’s mother, holding George.
The two mothers embrace – and, in a way, so do the two teddy bears.
Family members have submitted ‘victim impact’ statements to the court.
Judge David Turner QC says: “The victim impact statements were very moving… We can’t ignore six years of disaster for the families.”
But Turner adds he initially wondered why Network Rail had pleaded guilty. He says he subsequently understood after reading a bundle of documents submitted by Network Rail.
Pleading guilty facilitates a one-third reduction in any fine imposed.
The company submits a mitigation statement.
Prosecutor Jonathan Ashley-Norman says the “delayed disclosure” of the Hill risk assessment and Hudd memo impacted negatively on the coroner’s inquest and “is an aggravating feature” of the prosecution.
On the Hill risk assessment and Hudd memo, judge David Turner says: “We are not into the realm of a deliberate distortion of the process. An inquiry into what happened to the papers would be a fruitless investigation.”
But Turner then adds: “The Hudd document is a seriously concerning piece of paper. I trembled at the prospect of further litigation. I do not want to get bogged down but I did find the disclosure slightly strange.”
Turner speaks on the issue of whether Network Rail’s failure to disclose the documents to the original investigators and to the coroner amounts to an intentional obstruction of the judicial process. “That would have been very sinister,” says Turner. “But I have to put that out of my mind.”
The prosecution says Network Rail’s non-disclosure of the two documents amounts to serious incompetence, even if willful obstruction cannot be proven: “But that is not to play down the late disclosure as it prevented the ORR from constructing the history of events up to the 3rd of December, 2005.”
The prosecution says Network Rail displayed a “corporate blindness” towards the frequent erroneous usage of the crossing. There was also a “misplaced over reliance on the miniature warning lights”.
Effectively, Network Rail accepted the “flawed” data analysis, risk scores and conclusions of Hill’s May 2002 risk assessment but failed to act upon Hill’s common-sense recommendation in Part B to install locking footpath crossing gates.
The judge also hears how Network Rail’s “want of vigour in the aftermath of the accident also gave rise to concern”. This includes claims by Maryanne Rosse, the level crossing research manager since 2004 – and subsequent whistleblower – that a backlog of remedial actions on level crossings existed following their risk assessment – and that Elsenham’s flawed risk assessment was part of a wider “systemic failure”.
The judge seeks to distinguish between Elsenham and other rail disasters, such as Ladbroke Grove and Hatfield. The ugly question of money arises. How much will be Network Rail be fined? Will this seem to put a monetary value on the lives of two young girls?
“A proportionate view is needed,” says Turner. “Things can go wrong on the railways, in such a complex operation.”
But judge Turner QC adds: “Network Rail, in part by itself and in part through its predecessor Railtrack, failed to ensure that the risks were properly assessed, controlled or managed.”
Prashant Popat, counsel for Network Rail, says: “Network Rail failed to make the crossing as safe as reasonably practicable. Network Rail apologises unreservedly for these failures and accepts entirely the offences committed. The company is committed to taking all reasonable steps to make sure it is prevented from happening again.”
In mitigation, Popat admits the risk assessments were inadequate. Near-miss and other incidents at Elsenham failed to be added to a database.
Train and passenger movements were not analysed. Ticket machines ought to have been located on both platforms.
Popat says Network Rail does not blame the individuals who carried out the risk assessments. He repeats that a route production manager, Jo Green – now Jo Kaye – stated in writing she has no recollection of the Hudd memo.
As for the memo, Popat says: “Tragically, Mr Hudd signed off Mr Hill’s 2002 risk assessment but did not refer to his own 2001 memo.”
However, Popat says the company’s lack of consideration to install other safety measures stems from these unsuitable risk assessments. One or more of the alternative control methods – locking gates, second train audible warning and a footbridge – could have been installed and prevented this tragedy.
Popat says the risk assessments undertaken between 2002 and 2005 were compliant with the rail industry standards agreed by the Her Majesty’s Railway Inspectorate and by the rail companies. Similarly, Popat says the emphasis on miniature warning lights was backed by HMRI.
Popat adds the HMRI and the rest of the rail industry also believed that people could be trapped on footpath level crossings because of locking gates. “That is an incorrect view but it was not just held by Network Rail but by the whole industry,” he says.
Popat says purpose-built, marked police CCTV vans monitor the use of the crossing. East Anglian police have helped raise awareness of how to safely use the crossing.
13. Fine ‘implications’
Popat tells the Judge David Turner that Network Rail’s investment in public safety will be hit by the imposition of a severe fine over Elsenham. He says the company promptly accepted guilt at the magistrates court in January 2012.
Network Rail, he says, has taken all steps to improve safety at Elsenham and overhauled risk assessments. Popat even goes as far to suggest to the judge that any fine should be comparable to the £75,000 fine that Network Rail received for a level crossing fatality four years previously.
In November 2010, the company was fined £75,000 and ordered to pay £36,791 costs at Newcastle Crown Court after pleading guilty to a health and safety offence involving the West Lodge level crossing. This followed an ORR prosecution over the death of Christopher Walton, a 17-year-old struck and killed by a freight train at West Lodge level crossing on the Blenkinsopp Estate, Haltwhistle, on 22 January 2008.
ORR found Network Rail should have reduced the risk of using the crossing, such as instructing pedestrians to telephone the signaller before crossing. Routine Network Rail inspections between 2005 and 2008 failed to recognise the ongoing risks at West Lodge.
The death of Christopher Walton echoes in some ways how Network Rail failed to protect Olivia Bazlinton and Charlotte Thompson. Walton and a colleague were delivering coal to a house next to the West Lodge crossing. They carried the sacks across the footpath crossing and returned with the empty sacks.
Walton, crossing from the house to the A69 trunk road, was struck and killed by a freight train travelling from Carlisle towards Newcastle.
According to the ORR, Network Rail had carried out a 2005 risk assessment that identified inadequate sighting distances at the crossing. The risk assessment detailed options to improve safety, including the provision of whistle boards or signs instructing all users to telephone the signaller before crossing.
However, Network Rail did not act on the findings of the risk assessment. The company only installed such signs to comply with an improvement notice served on it by the ORR.
Popat, acting behalf of Network Rail, now seeks to turn the West Lodge fatality to the company’s advantage over its looming fine for Elsenham. It’s Popat’s final mitigation point – and some family members on the public benches whisper an audible complaint, ‘So it all comes to down to money.’
Popat concludes Network Rail’s mitigation, saying: “Whilst recognising the tragedy and the gravity of its consequences, we ask your honour to place the breach in the context of these mitigating factors when assessing the appropriate penalty.”
Turner describes Network Rail’s submission as “helpful and balanced”.
The court adjourns.
PART 13: Thin ice 1. Sentence 2. Penalty 3. ‘Cover-up’ 4. Network Rail reaction 5. Johnson’s Crossing: Katie Littlewood 6. RAIB report 7. Johnson’s Crossing and Elsenham 8. Kings Mill 9. Grayrigg fine 10. Voice warnings 11. Headphones 12. ‘Rail Life’ 13. Mexico 14. ‘See track, think train’ 15. Bayles and Wylies 16. Motts Lane
Outside in the foyer, Reg Thompson reflects on what he has heard in court. “Network Rail knew the ice was thin, but they allowed the girls to skate on it,” he says.
On the matter of a justice and the impending fine, Thompson says it has little to do with natural justice and much more to do with a form of corporate justice, mitigated with the help of expensive lawyers funded by taxpayers.
It’s 3.20pm – and Judge David Turner QC is keen to complete his sentencing that afternoon – and spare the families any further agony.
Turner acknowledges for the record the “six year ordeal” suffered by the girls’ parents and families, intensified by the protracted inquiries since 2005. “There is not the slightest doubt at the upset,” says Turner.
In his sentencing remarks, Turner acknowledges the girls were in no undue rush and were not agitated when their Cambridge-bound Down train passed before them and they opened the pedestrian wicket gate on the Up side. “They were probably holding hands,” says Turner. (Alison Dinsdale, a witness, has said the girls appeared to link arms).
Turner says Network Rail failed to ensure the risks of using the Elsenham crossing were properly assessed, controlled and managed. Risk assessments were inadequately acted upon.
Risk assessment standards were deficient. They did not convey incidents of erroneous crossing usage. They did not differentiate between erroneous usage, misuse and abuse. Written records of incidents in the Occurrence Books were not entered into the computer database so they might have been analysed.
“That lack of information is conspicuous,” says Turner.
Assessments did not take into account that ticket machines and the ticket office were all located on one side of the tracks. They also had no method of calibrating passing trains and pedestrian usage – and failed to take into account the level of demand placed on the footpath crossing by the large number of people using Elsenham station.
Finally – and critically – Turner says Network Rail did not act upon comments made in previous risk assessments of Elsenham.
“It is a real concern that Network Rail’s system and procedures did not identify risk factors or even satisfactorily calculate them,” says Turner.
“The deaths of Olivia and Charlotte were not the first at Elsenham,” continues Turner, referring to the death “in similar circumstances” of a 69-year-old lady at the crossing on 20 November 1989. Turner recounts how the HMRI recommendation for a second warbling audible alarm – to warn of a second coming train – was debated within the rail industry but never implemented. “This was also never revived in subsequent risk assessments of Elsenham,” notes Turner. “The risk assessments lacked essential vigour.”
“The memo of May 2001 seems chillingly prescient with hindsight,” says Turner, mentioning the staggered layout of the platforms. “The scenario Mr Hudd foresaw is precisely that of the third of December, two thousand and five.
“Hudd commented on the confused layout of the crossing,” continues Turner. “Hudd commented on ways of mitigating the hazards. This was not a formal risk assessment but identified hazards that played a role four years later. His memo foresaw what happened. All of his suggestions have now been adopted by the company as remedial actions.”
Turner considers Network Rail’s mitigation aimed at reducing any financial penalty.
Turner says Network Rail had participated fully in revising the basis for risk assessments – before the tragedy occurred. The rail industry had begun research in 2001. Turner says safety provision at Elsenham met rail industry standards – as they existed at that time.
The “late disclosure” of Hudd’s memo and Part B of Hill’s risk assessment “hampered the ORR investigation and protracted them and the prosecution”. But Turner says the ORR concluded “it was not a deliberate failure to disclose the information”.
(Turner’s statement does not accurately reflect the nuances of the ORR’s conclusion, chiefly that it said it could not find sufficient evidence of deliberate non-disclosure by Network Rail).
“But the anxiety and distress of the families has undoubtedly been prolonged,” continues Turner. “But I do not treat that as an additional aggravating factor.
“Civil proceedings involving the families were seriously compromised,” he adds.
Citing previous cases, Turner acknowledges Network Rail’s mitigation point about the need for a proportionate fine: “Any one pound of fine is one pound that cannot be spent on public safety. The object of the prosecution is to achieve public safety. The amount of the fine is to bring this message home to the public.”
Turner begins to wrap up his sentencing remarks: “I have concluded there was a clear history of inadequate risk assessments and a failure to take remedial action…That prevailed over a worrying number of years.
“There was a narrative of culpable corporate blindness and complacency going beyond the merely inefficient or even occasional incompetence, that even entered the realms of criminal failure.
“Warnings were unheeded. Critical questions were unasked. Remedial actions were unsatisfactorily delayed.”
Turner says any fine must reflect “society’s disapproval of Network Rail’s failures”. He says: “No fine I shall impose is intended to reflect the value of the two lives lost or the profound pain or loss felt after this tragic disaster.”
Turner posits the “uneasy dilemma” over sentencing faced by the court in this “anxious case”. An inadequate fine will not satisfy the public’s disapproval but a severe fine will hit farepayers, taxpayers and Network Rail’s ability to fund safety improvements.
“The message is those who run transport systems need to maintain eternal vigilance,” says Turner.
Judge David Turner QC fines Network Rail £1 million.
The company must also bear £60,000 costs and a £15 legal surcharge within 21 days. Network Rail requests 28 days to pay – and this is granted.
Outside the court, TV, radio and newspaper reporters huddle around Olivia and Charlotte’s families. “They took our daughters from us and they broke our hearts,” says Hilary Thompson, Charlotte’s mother.
The families regard the symbolic £1m fine as shambolic.
Chris Bazlinton, Olivia’s father, recalls hearing about a meeting, held a few days after the fatalities, where Network Rail route officials discussed three other near misses at the crossing that occurred just prior to the disaster. Minutes of that meeting were taken in shorthand.
Bazlinton and Reg Thompson disagree with the judge on the key point of deliberate non-disclosure. They say an inquiry into what happened to the Hill risk assessment and Hudd memo lies at the very heart of the Elsenham tragedy. Bazlinton asks: “Who within Network Rail knew about those documents? How high did the cover up go?”
They agree with Crown prosecutors who said in court that delayed disclosure of these two documents disabled the coroner’s inquest. The ORR agrees, but – after questioning Network Rail staff under caution – it could not find enough evidence to recommend to the Crown Prosecution Service that charges be laid. “We investigated and did not find sufficient evidence to bring any case,” says Ian Prosser, the ORR’s safety chief.
Thompson sounds more amenable to Network Rail’s claim that the company is now proactively engaged in making potentially dangerous crossings safer. “The Network Rail of 2005 and now are two different organisations,” says Thompson. “The people now in charge do have some integrity.
“But over the six years, if the people at Network Rail had any integrity, they wouldn’t have constantly brought us back to this point – to being forced to live through the moment when Charlie and Liv died.”
Thompson adds: “The horror of that day is always with us. The huge hole in our lives left by the absence of Charlie will never be filled. Every single day, I think about that day.
“Of course, there is no end. Charlie and Livvie would be alive today if Network Rail had put proper safety in place at Elsenham. The people who are responsible for what happened to Liv and Charlie probably still sleep at night. That’s the way the world is, I’m afraid.
“Time doesn’t cure.”
4. Network Rail reaction
Following the sentencing hearing, David Higgins says: “On behalf of Network Rail I apologise for the mistakes made by us in this tragic case that contributed to the deaths of Olivia and Charlotte.
“Nothing I can say or do will lessen the pain felt by Olivia and Charlotte’s families but I have promised the families that we will make level crossings safer, and we will deliver on that promise.
“Fundamental changes to the way we manage and look after the country’s 6,500 level crossings have, and are being made. In recent years we have reassessed all of our crossings and closed over 500. There is still much to do and we are committed to doing what is necessary to improve our level crossings.”
5. Johnson’s Crossing: Katie Littlewood
The Elsenham court proceedings at Basildon and Chelmsford are echoed and amplified by events on Saturday, 28 January 2012.
Katie Littlewood, 15, a local resident, makes her way to work at a charity shop. At about 1140 Littlewood reaches a footpath crossing at Johnson’s Crossing near Bishop’s Stortford – just three miles south of Elsenham.
Littlewood crosses despite warnings provided by a red miniature stop light and an audible alarm. She is struck and killed by a train.
The train has forward-facing CCTV. Footage indicates Littlewood may have been unaware of the approaching train until it was some 32 metres – or 1.1 seconds – from the crossing. Littlewood has no time to reach a place of safety.
Investigators are unable to establish whether her personal music device or smartphone were in use at the time of the accident – or whether she was wearing headphones.
Underlying elements of Johnson’s Crossing amplify those at Elsenham.
Between late 2003 and July 2011, train drivers report nine ‘near miss’ incidents at the crossing. There are also two fatalities. In January 2006, a woman steps into the path of a train with her hands covering her head. In September 2009, a man, who suffers from a mental illness, runs onto the crossing in front of a train.
Witness evidence says the level crossing team has a high workload, partly as the team’s Anglia Route has far more ‘high risk’ level crossings than other Network Rail routes. Witnesses indicate the operational risk team concentrates on clearing a backlog of risk assessments, rather than implementing measures to reduce risks at the level crossings.
The Level Crossing Risk Control Co-ordinator responsible for Johnson’s footpath crossing does not have prior experience of operational risk assessment work and no formal training, other than in the use of the ALCRM tool.
Anglia Route operational risk staff were not subject to probationary ‘sign off’ or formal mentoring. An Operations Risk Advisor did have experience of conducting operational risk assessments, but for signalling rather than level crossings.
6. RAIB report on Littlewood fatality
An RAIB report of December 2012 into Littlewood’s death says: “Network Rail had not developed a proposal to install a footbridge to replace the crossing, after an analysis undertaken in 2007 had shown that the benefits of so doing would exceed the costs.”
The RAIB’s report says this was a ‘causal factor’ that led to Littlewood’s death. Johnson’s footpath crossing was risk assessed in 2007. Network Rail considered options to mitigate or eliminate risk.
In October 2007, the Level Crossing Risk Control Coordinator (LCRCC) obtained a positive cost-benefit analysis to replace the crossing with a footbridge. The Route Operations Manager discussed possible installation with an Operations Risk Advisor in July 2008, and approved a feasibility study.
But the feasibility was never carried out. Witnesses tell the RAIB that Anglia route staff believed funding rules made it almost impossible to receive monies for such studies.
An Anglia operational risk team tracking sheet records that funds were sought for the feasibility study in November 2008. A key witness says this was rejected – although no documentary evidence of this rejection materialises.
The Route Operations Manager nor a former Route Enhancements Manager could recall a proposal for a bridge or find any record of a funding submission.
A census and ALCRM assessment was conducted in December 2009. An Operations Risk Control Coordinator, similar to an LCRCC but now with an expanded role, visits the site in June 2010.
But it was not until November 2010 that a new ORA signs off a second positive cost-benefit analysis of a footbridge replacing the crossing. This ‘sign off’ led to a project to install a footbridge and close the crossing.
In a tragic irony, the project is in progress when Littlewood is killed in January 2012. The footbridge is installed and the crossing closed in August 2012.
7. Johnson’s Crossing and Elsenham
The history of the rail industry’s attempts to mitigate risk earlier at Johnson’s Crossing also echoes that at Elsenham.
Various proposals to close Johnson’s footpath crossing were not translated into action before 2007.
A fatal accident occurs at Johnson’s Crossing in August 1992 when a woman is struck by a Liverpool Street to Stansted Airport train.
Children, elderly people and other pedestrians are nearly hit by trains in seven reported ‘near misses’ between 1993 and 2000, according to the Safety Management Information System (SMIS), the computer database that records rail accidents and incidents.
In August 2002, a train strikes an elderly woman and her dog on the crossing. After this fatality Health and Safety Executive issues an ‘improvement notice’ to Railtrack, the company still responsible for rail infrastructure at that time. The notice requires the installation of miniature stop lights at Johnson’s Crossing and at nearby Cannons Mill Lane.
Railtrack is ‘again’ encouraged to consider closing one or both of the crossings. Railtrack installs the MSLs at both crossings by the end of October 2003.
8. Kings Mill
Other tragedies occur after Littlewood’s death and the Elsenham court proceedings.
In May 2012, Philip Dawn, a cyclist using a footpath and bridleway crossing at Kings Mill, near Mansfield in Nottinghamshire, is struck and fatally injured by a passenger train.
9. Grayrigg fine
In April 2012 at Preston Crown Court, Network Rail is fined £4m and ordered to pay costs of £118,052 for a breach of health and safety law that caused a passenger train to derail near Grayrigg in 2007 and led to the death of Margaret Masson and 86 people injured.
Network Rail would have been fined £6m but a guilty plea ensures a £2m reduction.
Mrs Justice Swift says: “The importance of implementing safe and adequate systems for the inspection and maintenance of the infrastructure is paramount, in order to ensure that accidents like Potters Bar and Grayrigg do not occur.”
At Lancaster Magistrates’ Court in February, Network Rail had pleaded guilty to one charge under section 3(1) of the Health and Safety at Work etc Act 1974, following a prosecution brought by the ORR. The charge results from the company’s failure to provide and implement suitable and sufficient standards, procedures, guidance, training, tools and resources for the inspection and maintenance of fixed stretcher-bar points.
The ORR’s Ian Prosser says: “Under David Higgins’ leadership, Network Rail is focused on driving safety measures and I welcome the company’s progress on implementing safety recommendations made after this incident. But the pace of improvements has, at times, been too slow and the rail regulator has had to repeatedly push the company to bring about change.”
Sir David Higgins, Network Rail chief executive, says: “Within hours it was clear that the infrastructure was at fault and we accepted responsibility, so it is right that we have been fined. Since the accident, much has changed in the way we plan and carry out maintenance work with new systems put in place to improve the quality and safety of our railway, which is why we now have one of the safest passenger railways in Europe.”
Solicitor Soyab Patel, speaking on behalf of Mrs Masson’s family, says afterwards: “The fine of £4m, together with costs, will ultimately be borne by the taxpayer. Mrs Langley (Mrs Masson’s daughter) is a taxpayer.
“Her mother died in the crash. She and her husband suffered serious injuries. She finds it offensive she is contributing to the fine.”
10. Voice warnings
In July 2012, Network Rail begins installing spoken warning equipment at 63 level crossings across the country, alerting pedestrians and motorists that, while one train has passed through, another train is coming from the other direction.
The company announces these spoken warnings will more clearly reduce the risk of someone mistakenly believing that it is safe to cross after the first train has passed.
Spoken warning equipment is installed near York at Hunmanby Station, Nether Lane, Cranswick and Arram level crossings and near Selby at Wressle and Eastrington. The new alarm now states: ‘Warning. Another train is approaching.’
These crossings have two-tone yodels, where the second tone sounds higher pitched and at an altered frequency to warn people waiting that a train is approaching from the other direction.
Research by the RSSB, entitled Examining the benefits of ‘another train coming’ warnings at level crossings, suggests voice messages mixed with standard tones are more likely to be understood and obeyed. A successful trial at Scarrington level crossing in the East Midlands advances Network Rail’s plans to install the technology at other level crossings with no audible alarms.
The voice warnings are part of Network Rail’s £130m investment in reducing the risk at level crossings up until 2014.
These devices are exactly the kind of measures that Chris Bazlinton, Olivia’s father, believes would have saved the girls’ lives if it had been in place at Elsenham in 2005.
In August 2012, Network Rail launches Lose Your Headphones, another level crossing safety awareness campaign. 2012 is also the year when two people have died at footpath crossings where it is thought they may have been wearing headphones –including, possibly, Katie Littlewood.
Train drivers and railway staff have reported 19 incidents where pedestrians, joggers and cyclists wearing headphones have crossed the railway, seemingly oblivious to an approaching train.
Network Rail deploy rap artist Professor Green to encourage people to remove their headphones at level crossings so they are not distracted from warnings about approaching trains. The digital campaign features a video that appears on music streaming service Spotify – and promoted on social media such as Twitter.
“I’m asking, please, lose your headphones when at a level crossing and pay attention to the all the safety warnings,” says Professor Green. “I don’t want anyone to end up on the tracks listening to one of mine.”
Martin Gallagher, head of level crossings, adds: “If Professor Green is asking people to stop listening to his music just for a few minutes, we hope people will listen up, lose their headphones, and not their lives.”
Dr Bruno Fazenda, from the Acoustics Research Centre, University of Salford, says: “There is plenty of evidence which shows that when you are listening to music or texting and crossing a railway track, your attention gets divided in such a way that you might not notice an approaching train even if all the warning signals are there.”
12. ‘Rail Life’
Network Rail also launches Rail Life, an initiative that includes assembly kits and lesson plans for schools. The initiative also contains a website showing CCTV footage of people narrowly escaping being hit by trains on footpath level crossings. It also shows Network Rail and British Transport Police staff interviewed about their experiences of being on duty in the aftermath of young people being killed by trains.
The RAIB also publishes a 2012 report into the death of a pedestrian in October 2011 who was killed after being struck by a train on the Mexico footpath crossing, near Penzance in Cornwall.
On approaching the crossing around a curve, the train driver saw a woman standing to the side of the line. The driver sounded a warning horn immediately before the train reached the crossing but the pedestrian tried to cross and was struck.
The RAIB recommends that Network Rail improve sighting and warnings at Mexico – and also that the company “develops a national approach to the location and marking of decision points at level crossings” and “optimises warning arrangements for pedestrians at level crossings provided with whistle boards”.
In January 2012, Network Rail moves a sign on the south side of Mexico footpath crossing to a position close to the tracks – but it also applies to Cornwall Council to close the crossing and divert users to the nearby Long Rock crossing where barriers stop pedestrian access to the tracks when trains approach. The closure proposal provokes some local opposition from people concerned that by no longer exposing pedestrians to the risks of the railway, Network Rail is increasing pedestrian exposure to the dangers of the roads.
14. ‘See track, think train’
Since April 2012, five people are killed at level crossings, including two pedestrians. More people are killed at footpath crossings than any other type of crossing. Since 2007 there have been 24 fatalities at footpath crossings out of a total of 46 fatalities at all level crossings.
By autumn 2012, Network Rail still operates around 3,000 footpath crossings, around 2,500 user worked crossings, and around 200 station crossings, including Elsenham.
In late October, the company closes its 600th level crossing since 2009 as part of the £130m programme. The company has closed 100 in the last year and aims to close a total of 750 by Spring 2014.
In October 2012, Network Rail launches a new level crossings television advert urging people to ‘See track; think train.’
The advert shows a family cycling slowly through the countryside. Their game of ‘I Spy’ distracts them as they approach the footpath crossing. The daughter stands on the crossing and realises the answer to ‘I spy with my little eye, something beginning with ‘t’, is ‘track’.
She then hears the approaching train sound its horn and realises she is in its path. But it is too late and the train presumably strikes her.
A voice over a written message says: “Distractions can cost you your life. See track. Think train.’
Martin Gallagher, head of level crossings, says: “While fatalities at level crossings are low, there have been more pedestrians killed at crossings in recent years, and so we wanted to focus our campaign to connect with this audience.”
The £1m ad campaign runs for three weeks across terrestrial national TV – shown in breaks during hit UK shows Coronation Street and Downtown Abbey – and on regional TV and satellite channels, Sky Sports, Sky 1, Dave and FiveUSA.
15. Bayles and Wylies
In November 2012, a young woman is struck and fatally injured by a tram when using the Bayles and Wylies crossing at Bestwood in Nottingham. Later, Network Rail closes the crossing in February 2013 pending the construction of a footbridge.
16. Mott’s Lane
A man with a bicycle crosses a two-track railway on a footpath and bridleway crossing at Mott’s Lane, near Witham, Essex, on Thursday, 24 January 2013. At about 1737 he is struck and instantly killed by a train travelling from London Liverpool Street to Norwich.
The crossing links a residential area with an industrial estate. Red and green safety lights protect users – but the crossing has a history of wrongful use. The RAIB investigates.
PART 14: New safety measures 1. ‘Learning lessons’ 2. Level crossing managers 3. Wave Train 4. Smartcams
New safety measures
1. ‘Learning lessons’
Network Rail publishes a ‘safety sustainability update’ for 2011/12. The document states: ‘We pleaded guilty over safety breaches in relation to the fatalities at Elsenham level crossing in 2005 and the derailment at Grayrigg in 2007. Both were serious events where people lost their lives.
‘We have learned lessons from both incidents and put our learnings into practice.’
In July 2013, David Higgins and Robin Gisby are present at a Network Rail board meeting where Higgins leads a discussion on health and safety. The minutes state: ‘The three recent level crossing incidents…once again served to underline that level crossings were the biggest risk on the railway and should not be neglected.’
The company reports an 8.5% decrease in the rate of ‘significant’ level crossing incidents in 2012/13 since the previous year.
Nine accidental fatalities occur at level crossings during 2012/13. They include five road vehicle occupants (including one child) and one cyclist.
Three pedestrians die.
Network Rail claims level crossing risks are reduced by 5.5% during 2012/13. Risk overall has fallen 22.8% during the Control Period 4 (2009-14), closing in on the target of a 25% risk reduction target by the end of CP4 in April 2014.
117 level crossings are closed in 2012/13. For instance, Downham Market station barrow crossing is closed in 2012/13, as are Tallington footpath crossings, and Whitacre Junction and Hogrills End (Whitacre East) level crossings.
The National User Worked Crossing (UWC) level crossings closure programme closes, or is in the process of, closing over 660 UWCs.
Modular footbridges are erected at Johnson’s Crossing – where Katie Littlewood died on the Anglia route – and at Cooks Crossing on the East Midlands route, enabling the crossings to be closed. Detailed plans are developed to enable another 33 closures in 2013/14.
Another 28o crossings are surveyed for planned closure in CP5 (April 2014-19).
Spoken audible warnings are installed at 23 locations. British Transport Police begin patrolling each route in 13 new mobile safety vehicles.
2. Level crossing managers
Level crossing managers, dedicated to each route, begin work in Scotland in June 2012. LCMs are allocated to all other routes in 2012-13. Each LCM receives ‘comprehensive training’. Improved guidance materials and risk assessment tools are developed for them.
Level crossings continue to evolve. Research and development includes three digital red light safety cameras submitted for Home Office approval. Six trial sites are identified.
Systems to provide information to signallers or crossing users about the location of trains in long signal sections are developed.
A Global Positioning System (GPS) is trialled on the Sudbury branch.
3. Wave Train
In March 2013, Network Rail provides information about Wave Train, a ‘pioneering scheme’ that ‘listens’ for approaching trains.
Steve Hooker, Anglia route infrastructure maintenance director, says: “The traditional way to install a miniature level crossing warning system is to hard wire it into the signalling system. That takes about two years to plan, and would likely involve a 29-hour blockade to install.
“Wave Train provides all the same benefits, but it can be up and running within hours, and it doesn’t require all that preparation work. If we decide to install Wave Train at a level crossing, we can have it there pretty much the next day.”
Trials at 48 selected Anglia route level crossings are deemed successful. Network Rail in house maintenance staff fit small microphones to the rails. Wave Train then detects sound frequencies generated by rail vehicles travelling over the tracks. Detected unique frequencies set off light and sound warnings at level crossings.
Only one microphone is needed but eight are fitted at each installation. If one microphone fails, the systems continues to function. A failure message is sent to a maintenance manager.
If the entire system fails, a light at the side of the level crossing tells crossing users that the system has shut down and they should cross with caution. Total system failures also trigger an ‘urgent’ message being sent to the maintenance manager.
No trackside cabling is needed. All components are installed within 15 metres of a level crossing.
Wave Train is installed at level crossings where there is no warning system, or where it safety would be significantly improved. The first level crossings where the kit is installed are chosen because of:
- evidence of regular crossing ‘misuse’
- a Temporary Speed Restriction on approaching trains is in place due to sighting issues for crossing users at crossings currently with no warnings or alarms
Wave Train is not replacing existing safety systems already installed at level crossings.
Richard Tew, Anglia route safety improvement manager, says: “The system is quite simple from an installation perspective. But built into the equipment is a lot of science and technology, and it’s that which is helping reduce risk.
“The major driver for this is safety, but we’ll get performance benefits too. That’s because where we have temporary speed restrictions (TSRs) due to sighting issues at some crossings that don’t currently have warnings, the installation of Wave Train will allow us to remove that restriction.”
Network Rail also herald Wave Train’s potential cost benefits, saying it is ten times cheaper than hard wiring one ‘traditional’ miniature level crossing warning system into the signalling. “For every system installed using previous methods, we can install ten Wave Train systems for the same money,” says Hooker. “Yet it’s able to deliver the same safety benefits, and is really helping us reduce risk at level crossings on the route.”
Hooker says Anglia Route will lead the initiative and provide other Network Rail routes with detailed information. Hooker says optimistically: “Working with the developer, and keeping other routes involved, we’ve put together a system that’s simple, reliable, easy and cost effective. If the system’s kept uncomplicated like it is now, I believe it could prove beneficial across the network.”
Wave Train is originally developed in Norway. Trialled for two years between 2011-12, the system withstands extreme weather such as snow and flooding.
Portable versions can be developed. This would allow temporary installation at a crossing on a farm during harvest season.
Portability would also help make track maintenance crews safer.
WaveTrain Systems was founded in August 2009 after research and development by NORSAR, a research foundation specialising in seismic software research. The company says: “We are very delighted to announce the signing of a breakthrough contract with Great Britain’s railroad authorities; Network Rail. The contract for a trial project of significant scale, by far the biggest contract in the history of WaveTrain Systems (WTS), is the marking of a tremendous leap forward.
“At WTS, we are extremely excited to be part of modernizing (sic) Britain’s infrastructure, as well as drastically improving the safety of the British people.”
Smartcams are trialled at Cannock Chase in Staffordshire. They automatically collect census data, identify user groups, calculate the times it takes to traverse a crossing, and quantify ‘misuse’ data. The RAIB recommends their use after the death of cyclist Philip Dawn at Kings Mill level crossing in May 2012.
PART 15: Inquiry by MPs 1. Robin Gisby evidence 2. Louis Ellman MP 3. Legal advice issue at inquest 4. Tina Hughes and role 5. Moor Green 6. Gisby evidence in detail 7. Elsenham: “Watershed” for Network Rail 8. Misuse of ‘misuse’ 9. Ministerial ‘misuse’
Inquiry by MPs
1. Robin Gisby evidence
At the time of the Elsenham disaster, Robin Gisby is responsible for day-to-day operations as Network Rail’s director of operations and customer services. In late 2013, Gisby is an executive director, as managing director for Network Operations. He remains the man in charge of running the UK’s railway on day-to-day basis.
Gisby and his department are responsible for train paths, timetabling and train movements. Network Rail’s ten route managing directors are accountable to Gisby. They must ensure the company improves the rail network’s performance and safety.
In November 2013, Gisby appears before Members of Parliament on the House of Commons Transport Select Committee. The cross-party committee of MPs is holding an inquiry into level crossing safety across the UK.
The mean rate of fatal accidents at level crossings has fallen to 6.40 per year in the first two years of the second decade of the 21st Century – a drop from 10.56 fatalities per year between 2000-10.
Network Rail has closed some 700 crossings since 2009 in a £130m programme that it claims reduces risk to crossing users by 25%. But the ORR still believes improved safety design, management and operation can further reduce risks and lessen the number of serious incidents and fatalities. Level crossings make up nearly half of the risk of catastrophic train accidents on the UK’s railways, (not including trespass and suicides).
MPs on the Transport Committee are keen to hear from Network Rail about its progress in reducing level crossing risk in the future.
Olivia Bazlinton’s mother, Tina Hughes, and father, Chris Bazlinton, sit behind Robin Gisby in the Grimond committee room in Portcullis House, the MPs’ office building opposite the Houses of Parliament. Later, they will hear what Gisby has to say about Network Rail’s actions before and after the deaths of Olivia and Charlotte.
2. Louis Ellman MP
Louis Ellman, an elected MP for Liverpool Riverside since 1997, and a member of the House of Commons Transport Select Committee since her election, chairs the committee. In May 2008, Ellman is selected as the chair after the death of Gwyneth Dunwoody MP.
Dunwoody, once voted ‘Battle-axe of the Year’ by a magazine, is a tough act for Ellman to follow. Dunwoody is remembered fondly for her acerbic and fiercely independent chairmanship of the Transport Committee, where she cast party allegiances aside to scour government ministers to reveal the truth, and to discomfit railway industry representatives.
Ellman and her committee members ask if expenditure on level crossing safety can be prioritised in relation to other demands on the rail budget. Are government and the ORR doing enough in relation to level crossing safety? How should level crossing law be updated? How can public awareness of level crossing risks be raised?
On October 21, the committee hears the first of two tranches of oral evidence. Ellman invites Chris Bazlinton, sat alongside Tina Hughes, to begin. Bazlinton says: “Five years after the accident, at the end of 2010, we discovered that Network Rail had failed to disclose two highly relevant documents.
“These were, first, a memo, which we have often referred to as the Hudd memo, from a level crossing manager, who in 2001, four years before the accident, had outlined exactly the circumstances faced by Charlie and Olivia and stated that ‘the risk of disaster is real’; and, secondly, a risk assessment in 2002, three years before the accident, which suggested that the gates ought to be locked. Neither of these had been acted upon. If so, they would have saved Liv’s and Charlie’s lives.”
Bazlinton continues: “I believe Network Rail’s actions over the non-disclosure of documents amount to a conspiracy of silence, or worse…I still want to know from the people at the top, who are ultimately responsible, why they withheld those documents, and why I should believe it will not happen again.
“This is about accountability, and it is important that we know what happened within Network Rail. They have never held a proper inquiry and told us what really happened.”
Ellman asks Bazlinton about the whistleblower and the two documents. “Everything happened over a couple of years,” replies Bazlinton. “They built the bridge, the inquest was held and so on.
“After that there was a period of three years when little happened except that Tina and Reg, Charlie’s father, took out a civil case against Network Rail. The company demanded twenty per cent guilt on behalf of the girls, blaming them for the accident.
“Eventually, that crumbled, but at the time I was approached by someone representing an employee of the eastern region whose job was under threat. She said that it was all to do with Elsenham.
“The person asked her what this was about and she said there were documents never seen by the inquest and the official inquiries. He asked me whether I had these documents. I said I had not got them and that I did not think they existed.
“Over a period of time we found one of them, which led in 2011 to The Times publishing an article just at the time David Higgins joined Network Rail. Five weeks later, when the Office of Rail Regulation said they were going into Network Rail’s office and look through their files, they handed over the second document.
“They have always claimed that these were somehow just lost and had disappeared. I find it incredible that the two most important documents in the whole case somehow went missing. I do not believe it. I believe that senior managers at Network Rail knew about those documents. I do not think there is a paper trail; it was a cover-up done by people saying, ‘We’re just not going to talk about this.’”
At this point, Bazlinton apologises to MPs as he tries to contain his emotions.
Bazlinton continues: “One senior manager took the families up the track to the point where – I’m sorry – where Olivia’s body was recovered. He befriended us – sorry.
Ellman: It’s all right.
Bazlinton: “I am almost certain that the manager knew about the documents because he was in the line of responsibility. If he did not, he was a very incompetent manager. He reported to the very top and I believe that he knew, along with all the others up the line.
“The whistleblower knew about the documents. She said she sent them to head office. Head office deny that they ever received them, yet it has been proved they were in head office, so she was proved right.
“Somebody is either not telling the truth or did not look through the boxes properly. I do not know how to put it, but any rational person would say there was a cover-up there.”
Bazlinton lists several Network Rail officials in his formal, written submission to Members of Parliament sitting on a House of Commons Transport Select Committee inquiry into level crossing safety.
MPs are invited in October 2013 to consider Jo Green, a route production manager, who told the ORR she could not recall receiving the memo.
Phillip Heath, general manager for West Anglia rail region at the time of the accident, reportedly prepared a witness statement for the civil case brought by Tina Hughes and Reg Thompson against Network Rail. The company never uses the statement as it decides to concede and settle the cases.
But the company is said though to have used Heath’s statement as a press statement, published on its website in February, just as The Times newspaper reveals the existence of Hill’s Part B. The published statement and press release ‘disappears’ a few days later. In the statement Heath states he was not aware of any other serious incidents or problems at Elsenham – apart from the 1989 fatality – until the tragic event of 3 December 2005.
On the Friday after the tragedy, Heath is said to be present at a meeting. What was discussed at this Network Rail meeting? Were three ‘near misses’ prior to the tragedy discussed?
In the summer of 2010, as the civil cases are launched, Heath is said to have asked Mo Rosse, who first reveals the existence of Part B and the ‘Hudd memo’, whether she has any documents relating to Elsenham. Suspended at the time, Rosse says she does not have any.
Bazlinton, in his evidence, also raise several questions about other officials:
- Robin Gisby, managing director, network operations
- Richard Smith, solicitor, Network Rail
- Jon Wiseman, East Anglia route director in 2005
Wiseman, since retired, used to report directly to Robin Gisby. Wiseman gave evidence and answered questions at the Inquest but did not mention Part B and/or Hudd’s memo.
The ORR confirms Richard Smith knew about the documents, at least before The Times published its stories. As Network Rail’s solicitor, Smith ought likely to see all documents.
Bazlinton asks if anyone at Network Rail knew about the documents during the handling and eventual settlement of the civil cases brought by Tina Hughes, Stephanie Bazlinton and Reg Thompson?
Did anyone at Network Rail know about the documents during the coroner’s inquest at Chelmsford in January 2007? If so, were they present at the inquest itself?
And why did it take so long for the Hudd memo to be produced?
“The Hudd document was still withheld until ORR announced it was going to visit Network Rail to look through files in May 2011,” says Bazlinton. “It was handed to them the same afternoon and issued to the families by chief executive David Higgins that day.
How does the Hudd memo ‘suddenly appear’ when ORR officials go to look through Network Rail’s files on Elsenham?
Who knew about the Hudd memo?
Who knew about its whereabouts as the RSSB, ORR and RAIB investigations were undertaken?
Bazlinton regards the whole matter as a ‘cover up’ and as a perversion of the course of justice. “Network Rail withheld documents from us, official inquiries and from the coroner,” says Bazlinton. “I want to know what will the authorities do, because the inquest was a farce.
“We still have a lot of questions.
“Who knew about this?
“How high did the cover-up go?”
3. Legal advice issue at inquest
Martin Vickers MP asks about the support the family received, especially any legal advice during the coroner’s inquest in January 2007. “We were very well supported by British Transport Police in terms of family liaison, but there was no support for us through the inquest process in terms of legal advice,” says Tina Hughes. “We were not allowed legal aid, and we could not afford to employ a barrister or solicitor for four days to support us.”
Bazlinton tells Ellman and the other MPs: “We faced a bank of lawyers. There were three barristers and two solicitors paid for by the train companies and Network Rail.”
4. Tina Hughes and her role
Tina Hughes, Olivia’s mother, explains her approach to the committee members. “I am less interested in what has happened before and more interested in making sure Network Rail have made the changes David Higgins promised us would be made,” explains Hughes.
She tells MPs how Higgins, newly arrived at Network Rail – and in the midst of the revelations about the documents – established a national level crossing team, supported by £130m to manage risks and improve safety at crossings.
Higgins invited Hughes to become a ‘level crossing champion’ in 2011. Hughes retained a degree of scepticism about her appointment by Higgins, suggesting it might be seen as an attempt to placate a “hostile stakeholder”.
In November 2011, Hughes voiced criticism of Network Rail’s lack of accountability.
Two years later, Network Rail continues to benefit from Hughes’ passion as Olivia’s mother but also from her professional experience in project risk management. Hughes works for Atkins, a major civil engineering company.
Hughes tells MPs in November 2013: “I talk unashamedly to Network Rail staff and anybody else will listen to me about the trauma of Olivia’s death, not just for me and those who loved her but for everybody who was involved: the police, the train staff and the train driver.
“It is important that they understand the impact of these types of deaths and that is not just the percentage points of a risk reduction that they are achieving.
“I believe that her death resulted from a failure, not to measure the risks, but actually to have the resources to act upon those things. I believe those processes are now in place. Network Rail have recruited over 100 level crossing managers…These people own the level crossings – perhaps 70 or 80 of them each. They understand all the issues and the stakeholders involved…They work with local people to get crossings closed.”
Hughes says Network Rail always reacted to a catastrophic failure. “But I now see that they are beginning to be proactive and look at where the next accident might happen and start to make some changes to that. That really pleases me.”
However, Hughes cautions that senior management – beneath Higgins – cause a “significant problem”. They fail to recognise that the people who work on the ground for Network Rail are “an important asset”. Hughes adds: “The last two and a half years have seen significant progress, but it is vital for public safety that this work continues and that it is prioritised and supported by everyone throughout Network Rail.
“I work with them rather than for them. It is a very good position to be in because I can go in and I am not under threat of losing my job, as some people within the organisation feel that they are…I think things are changing, but they have a massive, massive amount of work to do.”
5. Moor Green
MPs on the Transport Committee are then given a stark reminder of the continuous and permanent nature of Network Rail’s level crossing responsibilities. Laurence Hoggart begins to read a brief statement about the death of his wife. Jean Hoggart and seven-year-old grandson Michael Dawson were killed on the Moor Green pedestrian crossing at Bestwood in Nottinghamshire in November 2008.
Hoggart’s emotions prevent him from reading aloud further. Peter Rayner, a retired British Rail chief operating manager for the London Midland Region – accompanying Hoggart – reads the statement on Hoggart’s behalf. It states: “It was dark and at the time there was no lighting on the crossing. They had to cross a tramline, two railway lines and a disused railway line. It was pitch black.
“The crossing was a dog leg, so they would have been facing away from the train when it hit them and they would not have seen it coming. The sounding of the horn had been moved further away due to complaints from homeowners, so Jean probably did not hear it.
“This has devastated my life and my family’s life. Jean was the backbone of my family, and it is broken now.”
Hoggart claims Network Rail treated him badly, writing just one letter of apology. He says his solicitors discovered that Railtrack had deemed the crossing unsafe in 2000 and recommended that a bridge be built.
“That was eight years before they died,” states Hoggart. “Nothing was done…They were only interested in making money…I sued them for some compensation, and right up until the week before the case was due they stood against me saying that Jean was 10% or 20% responsible…The small amount I received cannot take the place of my wife, a mother of five, a grandmother, a daughter, a sister and a friend…
“Network Rail did not even write or ring to tell me that a bridge was being built…I was not invited to the opening ceremony. If it had not been for the support of my next-door neighbour…I would be dead. I bought a rope and intended to kill myself.”
6. Gisby evidence in detail
Robin Gisby, now managing director of network operations, a position with a salary in excess of £380,000, answers questions from MPs on the committee during its second session of oral evidence held on November 4. Ellman starts by asking Gisby what his role was at the time of the Elsenham fatalities.
Gisby says he was “director of operations and customer services”. He adds divisions operated separately in 2005 – “in a bit of a silo structure” – but claims Network Rail has now “clarified accountabilities across the entire business, particularly for level crossings”.
“The creation of network operations has made everything clearer and it all comes through to me,” he says. But Ellman is less concerned with recent corporate changes than with past personal obligations. She asks: “Were you responsible for conducting the risk assessment at the time?”
Gisby replies: “People within the organisation I had at that time were responsible for filling in some of the data…The models being used and the algorithms and their application lay elsewhere within the business. As I said earlier, a lot of that has been tidied up and sorted out, and it is much clearer now than it was then.”
Ellman asks Gisby if he can explain why a Network Rail accident report stated Olivia Bazlinton and Charlotte Thompson were ‘trespassers’, even though they had bought tickets to travel by train.
Gisby: “No, I think it was quite inadequate and inappropriate. This morning, we were with Tina Hughes, and she raised exactly the same issue. That choice of words was completely wrong.”
(Hughes, in her role as level crossing user champion, spoke to the Network Rail board that morning – 4 November).
Gisby tells MPs: “I would like to think, in such very difficult circumstances, we wouldn’t behave as we clearly did after the Elsenham incident and others.”
He concedes deliberate trespass and misuse of crossings is insignificant compared to human error and misunderstanding.
Ellman switches to what Bazlinton says lies at the heart of the Elsenham tragedy: the two critical documents that were only revealed when a whistleblower drew attention to them. Ellman asks Gisby: “Can you tell us how the situation arose?”
Gisby replies: “I cannot easily. I do not know why those things were not produced. They certainly should have been; they were somewhere within the organisation, and we have investigated why they did not come out until much later in the day, as have other organisations.”
7. Elsenham: ‘Watershed’ for Network Rail
Gisby continues: “I believe we are now in a much different place, due largely – I pay tribute to them – to the actions of the families at the time.
“Elsenham was a fundamental watershed for this business.
“We were in a much worse place several years ago in how we managed level crossings, and we are better now…Tragically, we had an incident just this morning…Within a couple of hours now, we are able to get all the facts…and those data stand up much more than the appalling place we were back in 2005.”
Ellman persists with specific questions about Elsenham. Gisby tends to answer with references to current and general level crossing safety. Ellman asks: “Network Rail’s lawyers at the time argued that the risk assessments should not be given to the inquest. Why did that happen then?”
“I cannot be sure of the view of our legal team there,” before speaking about how risk assessments now are available as part of Network Rail’s “move to much greater transparency”.
8. “Negligent management”
Ellman brings Gisby back to Elsenham 2005 and its aftermath, asking: “Would you agree that it was negligent management at the time of Elsenham?”
“Yes,” answers Gisby.
“It was a watershed,” Gisby continues. “The state our company was in over the risk assessment, and, to be honest, the subsequent behaviour of the company towards the families involved, were quite appalling.
“…I pay tribute to Tina Hughes and others who have helped us get there. She has been magnificent in helping us in the last two or three years. I believe that the company is in a much better place, but there is still a long way to go.
“Crossing the railway is dangerous, whether it is on foot or by vehicle. We are doing all we can to minimise those risks and make it as safe as possible.”
Gisby tells Ellman that Network Rail have added a “narrative” element to data and algorithms used to assess risks to level crossing users. “We talk to train drivers and talk much more to the local community to get a much richer view of the current risk profile of a level crossing,” he says.
Gisby adds Network Rail will spend £109 million during 2014-19, a ‘ringfenced’ sum authorised by the ORR and supported by government ministers, to render risky level crossings safer and to close up to 500 deemed as dangerous. “We’ve still got a long way to go,” says Gisby.
Graham Stringer MP asks Gisby: “Will Network Rail still be taking public relations people to inquests?”
Gisby answers: “I’m not sure. That’s a good point. I’ve not considered it previously.”
Stringer: “You can see, can’t you, that if you’re tooled up with PR people, barristers and solicitors, that whatever you’ve said to the families of victims who may not have much money themselves, isn’t it very difficult for them to feel you’re being very fair with them?”
Gisby: “Yes, it’s a good point. I think it would depend on the circumstances of the incident, such as Network Rail’s level of culpability and involvement, and the families’ wishes. Five or six years ago, some of our behaviours were unacceptable. We were wrong, and I hope, should it happen tragically again, we would behave very differently.”
9. Misuse of ‘misuse’
Later, during that session, Ellman quizzes Stephen Hammond, the government’s parliamentary under secretary of state for transport, for his insistence on using the term ‘misuse’ of crossings during his opening statement to the committee.
Ellman says the term ‘misuse’ “only distracts from the gravity of the tragedy of bereaved people”. She says the committee has heard from bereaved people who are devastated by the death of their loved ones at level crossings – and in none of those instances was there anything that could be called ‘misuse’.
These cases were tragic accidents and, in some, there may have been liability where Network Rail knew there were risks but did nothing. Even Network Rail has vowed not to use the term ‘misuse’ loosely.
But Hammond, recently delegated the level crossing responsibility as a government transport minister, seems poorly briefed – and perhaps unaware Tina Hughes and Chris Bazlinton are present in the room – sat behind him.
Hammond tries to backtrack yet only compounds his error. “We need a greater programme of education so people clearly understand the risks they run,” says Hammond.
Ellman asks Hammond whether his Department of Transport is aware of the inadequacy of some level crossing risk assessment. “I will go back and make sure the Department is aware of any concerns,” says Hammond, in a faltering series of answers laden with uncertainty.
Hammond also seems unaware that families of victims are not entitled to legal aid at inquests. “I would hope Network Rail would wish to show every sympathy to the families of bereaved victims – and I’m sure that is what they tried to do. But who Network Rail choose to represent them at an inquest is a matter for them as a private company,” says the government minister.
9. Ministerial ‘misuse’
After Ellman closes the session, Tina Hughes and Chris Bazlinton, Olivia’s parents, informally approach Hammond and his advisers. They personally reproach Hammond for persistently misusing the term ‘misuse of level crossings’ during his evidence.
Bazlinton and Hughes impress upon Hammond that if a level crossing is deemed not safe it is surely wrong to say someone involved in an incident there has misused that crossing. Most accident victims misunderstand instructions at unsafe crossings; only a few deliberately misuse crossings.
Hammond appears to find the face-to-face encounter uncomfortable as Bazlinton and Hughes briefly yet poignantly hold a senior elected government minister to account.
Hammond listens politely but offers no direct reply. The minister then shakes their hands and leaves the room.
PART 16: Closing level crossings 1. Closure programme 2. Level crossing safety funds 2014-19 3. Level crossing managers team 4. Martin Gallagher 5. The Regulator and ‘leverage’ 6. Level crossing law 7. Risk assessment 8. Busier railway 9. Beccles prosecution 10. The 700th closure
Closing level crossings
1. Closure programme
Between 2009 and 2013, Network Rail closes over 700 level crossings across Britain, part of a £130 million investment programme dedicated to enhance level crossing safety. The company says £40m of this money comes from ‘efficiency’ savings generated elsewhere across Network Rail.
Crossings close. Footbridges are erected. Pedestrian gates are locked in tandem with train signalling.
Sixty-five crossings with ‘standard’ single tone audible warning alarms are upgraded to two-tone warnings indicating a second train coming. ‘Second train coming’ voice warnings are also installed at some crossings. CCTV is installed.
Anglia route manager Richard Schofield announces in October 2013 that work will begin to replace three level crossings in Hertfordshire – not far from Elsenham – with either footbridge or cycle bridges. “The new bridges at these Hertfordshire level crossings will provide the public with a much safer route across the railway,” says Schofield.
Thorley level crossing – passed over by frequent high speed trains – will close in March 2014. A footbridge at Mansers, a crossing where three instances of ‘misuse’ were reported in 2013, is due to open after January 2014. Cadmore Lane, a high-risk crossing, is to be replaced by a ramped cycle bridge by March 2014.
2. Level crossing safety funds 2014-19
In October 2013, the ORR says Network Rail will receive more than £21 billion between 2014 and 2019 to run the railways. Of this £5bn is for maintenance, and more than £12bn is for renewals designed to ease congestion and improve performance.
Included in the £21bn is a protected sum of £109m, dedicated to funding the closure of about 500 level crossings and to improving safety at hundreds more assessed as ‘high risk’. This includes £67m from the Department for Transport and an extra £32m added after Network Rail had asked for more money. Network Rail will start to implement the crossing closures as part of its delivery plan on 1 April 2014.
ORR chief executive Richard Price says: “Network Rail has made great strides in improving safety, performance and efficiency on Britain’s railways…This plan for Britain’s railways between 2014 and 2019 – informed by the public, consumer groups, governments and the industry – requires a safer, higher performing and more efficient railway.
“More level crossings will be upgraded or closed, passengers will enjoy punctuality, and suffer fewer cancellations…With increased levels of funding in vital areas such as safety, and closer monitoring from the regulator, we expect Network Rail to build on past successes and beat the challenges we have set.”
The company – and Hammond, the minister at the Department for Transport – make much of reaching a 25% level crossing risk reduction target in the 2009-13 control period – apparently one year early. A target of reducing risk by another 50% is set for the end of 2019.
Robin Gisby says this protected money should allow Network Rail to close another 500 crossings by 2019, including many where an alternative crossing exists within 200 metres. In November 2013, he says 282 crossings of different types are “classified as high risk with a possible consequence to the train, the pedestrian or the road vehicle user”.
Gisby says it is not possible to close all level crossings due to the way the railway was initially designed and also because of costs. But when rail lines are upgraded – such as the West Coast Main Line – Network Rail’s ten route managers, he says, ask whether a crossing can be replaced, by a subway or footbridge, rather than be merely upgraded.
Between 2010-12, Network Rail installs 55 low-cost footbridges at level crossing sites. Bridges are bulk-purchased to lower procurement costs by some £500,000, part of the benefits of a national programme.
3. Level crossing managers team
Since 2010, Network Rail has been introducing Level Crossing Managers, who are responsible for managing level crossing risk but also overseeing the implementation of measures that mitigate or eliminate those risks. The RAIB emphasises the importance of this role as it is ‘expected to reduce the potential for mitigation proposals to become lost between departments’.
To control level crossings nationally, Network Rail sets up a central level crossing team with Martin Gallagher in charge. The company appoints 100 level crossing managers. Some control between 70 and 80 crossings on their patch.
There are up to 15 varied types of level crossing so Gisby says these trained, specialist managers will be invaluable. “Previously, back in 2005, managing level crossings was a role split amongst other things people did,” says Gisby. “I think that was inadequate – and that the focus on it now is much better.
The managers conduct risk assessments using handheld devices, designed to eliminate the previous inefficiencies of pen and paper – and paper storage. They carry out crossing inspections, authorise minor repairs and take decisions on risk mitigation measures. They talk with local people. CCTV at some 650 open level crossings helps gather usage profiles to accurately inform risk assessments.
“We are not just relying on the cold numbers but asking broader questions on crossing usage,” says Martin Gallagher. “That is giving us a better risk profile than would have been the case in the past.”
In an experiment, a global positioning system provides crossing users with precise current information on train locations so they know when it is safe to use the level crossing on the Marks Tey-Sudbury line in eastern England.
“In the 21st Century we should be able to detect where trains are to inform people when it is safe to use a level crossing so they are not left waiting for up to twenty minutes,” says Gallagher.
Gisby says the company is introducing a whistle board that sounds at the crossing rather than coming from the train. Crossing users can hear the sound immediately rather than hearing it from some distance down the track.
4. Martin Gallagher
Network Rail’s head of level crossings Martin Gallagher seems confident. “Not that many people die at level crossings in Britain,” he begins. “There is an argument as a result that if not many people are being killed then it is not a problem and it is something that does not need to be addressed.
“However, this drives complacency and adds to the idea that it is the fault of pedestrians and motorists, and that we don’t need to do anything. Only when there is an unfortunate event like Elsenham are we alerted to the system’s failings. Our business case then is not just based on how much it is going to cost and the number of lives we might save, but on reducing the risk factor – and the fact that it is the right thing to do.”
Gallagher says: “When we complete our programme of risk assessment at every level crossing in the country in 2015, I expect to see that every one of them will have a higher level of safety and asset quality than we have ever seen before. We are still going to have accidents, but hopefully we are going to find that these accidents are not the result of the risk factors that we identify.”
Internal Network Rail issues about the management of Gallagher and his team arise in 2012 but are resolved.
5. The Regulator and ‘leverage’
However, the ‘leverage’ question keeps cropping up. Member of Parliament Sarah Champion asks the ORR’s Ian Prosser on 4 November if the ORR lacks leverage to ensure Network Rail makes things happen.
Prosser says he clearly told Network Rail several years ago that the company needed to systematically improve leadership of the management of level crossing risk. He also told the company to improve the quality of risk data and to embed the local ownership within the organisation of a level crossing. Prosser says he also told Network Rail to collaborate on crossing safety with train companies, train drivers and local people.
By November 2013, the ORR has served 22 level crossing improvement notices on Network Rail in the past five years – all enforced.
The ORR has 86 warranted safety inspectors. Of these 26 are engineers – eight with signalling qualifications.
Prosser says risk assessment and data collection has improved – and boasts that British level crossings are ranked as the safest in the European Union. “Collectively, the rail industry can do better at educating people who use and manage level crossings,” says Prosser.
Enforcing required improvements will also help but engineering level crossings to minimise and control risks to users is vital. “That also includes the highest level of controlling risks – which is to remove a level crossing completely,” says Prosser.
But RAIB chief inspector Carolyn Griffiths says the quality of the risk assessments remains a matter of concern. Some deficiencies are found in Network Rail’s algorithm. “Also, the person doing the risk assessment must look around their environment and take account of that site’s peculiarities,” explains Griffiths.
Network Rail’s level crossing managers should be able to take into account local factors, says Griffiths – as level crossings are their sole responsibility and not bolted as an add-on to their other main job duties as happened with other managers in the past.
6. Level crossing law
Level crossing law, according to the ORR is antiquated, some of it even Victorian – and does not follow modern health and safety at work legislation.
In 2008, in conjunction with the ORR, the Department for Transport commissions a report from the Law Commission. The Department receives the Commission’s report and recommendations – five years later – on 25 September 2013. Transport Minister Phillip Hammond tells MPs on 4 November: “We’re considering each proposal and hope to make some announcement in the New Year.”
A bill could follow in Parliament to better regulate level crossing safety and make it easier for the various rail industry bodies to work together more effectively to close dangerous ones.
7. Risk assessment
Network Rail sets out its processes for judging whether risk reduction or mitigation measures are ‘reasonably practicable’ in the current version of its Operations Manual. This sets out risk assessment and roles of the individuals involved.
Route General Managers are directly responsible to Robin Gisby for their management of risk reduction at level crossings. Operations Risk Advisors are answerable to the Route General Managers for ensuring all level crossing risk assessments are reviewed by a competent person. ORAs also review and approve proposals for level crossing closures and review risk reduction and mitigation measures recommended by Operations Risk Control Co-ordinators (ORCC).
ORCCs calculate risk at each level crossing using the All Level Crossings Risk Model (ALCRM) computer model. Other local risk factors at each crossing must also be considered. ORCCs also advise on level crossing matters and, importantly, maintain level crossing records.
Another staff group, Mobile Operations Managers, gather data at level crossings and complete a census that provides further information to assess level crossing risk. The census, conducted every three years, must be done on a weekday between the hours of 09.30-16.30, normally for a period of 30-60 minutes during which the number and type of user is recorded, and the user number is then multiplied to obtain an equivalent usage for a 24-hour period.
ORCCs are advised to use the RSSB’s Level Crossing Risk Management Toolkit when identifying measures that can mitigate or eliminate risks. ORCCs then apply a cost-benefit analysis to any measures deemed applicable. Where the safety benefits sufficiently exceed the cost of implementation, then the risk reduction measure can be applied to the crossing.
The Operations Manual now requires a risk assessment of each footpath crossing is carried out at least every three years. Accidents, or incidents like a near miss, trigger additional risk assessments, as do concerns about a level crossing raised by Network Rail, a train operating company or a local council.
Network Rail’s Operations Manual does not mandate usage of an alternative and wider cost-benefit analysis tool – taking into account reductions in ‘reputational risk, effect on stakeholders and insurance costs’. But Anglia region level crossing risk personnel are instructed on its use in November 2008 – over three years prior to the death of Katie Littlewood at Johnson’s Crossing.
The role of Level Crossing Manager is added to this operational structure. Network Rail centralises responsibility for level crossing management under a ‘separate asset area in National Operations’. Over 100 managers dedicated to level crossings are employed. Community safety managers raise safety awareness through work with local community groups, schools and councils.
8. Busier railway
Network Rail plans to create a busier and more efficient UK railway. In January 2013, Network Rail says it plans to boost track capacity so more trains can carry 170,000 extra commuter seats at peak times by 2019.
Higgins says: “One million more trains runs every year than ten years ago.”
Network Rail wants a railway that can move 225m more passengers per year and carry 355,000 more trains – a huge operational uplift. That includes 20% extra morning peak seats into central London.
9. Beccles prosecution
By the end of 2013, Margaret Masson at Grayrigg in 2007 is still the last on-board train passenger to die as a result of an accident involving a passenger train. Her daughter Margaret Langley, who travelled with her on the train, remains on medication.
However, an average of seven pedestrians and intending passengers are killed at footpath level crossings each year, although fewer fatalities occur at station crossings like Elsenham.
The regulator says Network Rail generally should undertake risk assessments that include ‘local factors, be realistic and genuinely have staff involvement’.
Network Rail is encouraged to further progress a ‘bow tie’ approach to risk analysis; chiefly ensuring that robust risk assessments are followed by ensuring that risk controls are implemented, operative and effective.
Concern lingers from the serious life-changing injuries suffered by a ten-year-old boy in a collision between a train and a car at a level crossing in July 2010. The train was travelling at 55mph when it struck the car at the crossing on a private road between Beccles and Oulton Broads South stations in Suffolk.
The collision spun the car, causing the boy to be thrown through a window. The car driver received minor injuries.
An ORR investigation found the accident was caused by poor visibility of trains approaching the crossing from the south side. ORR found Network Rail failed to act on information obtained from its employees over a ten-year period. This information highlighted that crossing users were exposed to an increased risk of being struck by a train.
In March 2013, Network Rail pleads guilty at Lowestoft Crown Court to a charge of breaching health and safety law. In June 2013, the company is fined £500,000 and ordered to pay costs of £23,421 following the ORR prosecution.
Ian Prosser, ORR railway safety director, says: “Our investigation found evidence that Network Rail knew the level crossing on a private road near Beccles was unsafe for ten years, and yet took no action.
“This led to the collision between the car and train which left a ten-year-old boy suffering life changing injuries. This is unacceptable from a company responsible for protecting the safety of millions of people on trains and at level crossings.”
10. The 700th closure
In July 2013, Network Rail closes Moors Gorse level crossing at Cannock Chase in Staffordshire – the 700th closed across Britain – around 10 per cent of the total – when Network Rail began its £130m national level crossing investment programme in 2009. Around 125 footpath crossings have been closed, says the company.
The crossing meant pedestrians and walkers had to negotiate two sets of gates to cross the busy Cannock railway line, where trains travel at up to 50mph. The crossing is now replaced with a bridge.
PART 17: A new era? 1. Higgins to leave 2. Network Rail debt 3. Barratt’s Lane 4. Lincoln 5. Essex closures 6. Bailey Lane 7. Union view of cost reduction 8. RSSB research 9. Risk increase of 7% 10. RAIB on risk increase 11. Safety and profits 12. Underspend 13. Transparency Panel
A new era?
1. Higgins to leave
By late 2013, Tina Hughes continues to work as level crossing user champion after being invited to take up the role by David Higgins. In October 2013, after the ORR determines Network Rail’s funding for its fifth control period, 2014-19, Higgins says: “The next five years for the railway will prove to be a critical challenge.”
But Higgins will soon be moving on to become the full-time chair of HS2 Ltd, the company responsible for developing High Speed Two, the controversial and conservatively estimated £42.6bn, Y-shaped high speed rail network linking London and the North, given a government go-ahead in January 2012.
In September 2013, Network Rail announce Higgins will be replaced as chief executive from April 2014 by Mark Carne, aged 54, a former Shell oil company executive vice president with an engineering pedigree.
Carne, married with three children, will enjoy a basic salary of £675,000. Carne, formerly Royal Dutch Shell executive vice president for the Middle East and North Africa, is touted as highly experienced when it comes to working in “volatile regions at a time of significant political change”.
Carne also ticks a safety box. When aged 29, Carne worked on the team investigating the Piper Alpha oil platform disaster where 167 men died in the North Sea.
“I am delighted to be given the opportunity to lead Network Rail and look forward to working with the team to drive performance to new heights,” says Carne.
2. Network Rail debt
Carne will take over Network Rail, a company that says £2.74bn, some £15m per day, was spent on new track, footbridges, concourses, information systems, platforms and lifts in the six months to the end of September 2013. That represents a 33 per cent rise in investment on the same period during 2012 and 53 per cent higher than in 2009.
But concern remains over Network Rail’s net debt. In March 2006, Network Rail debt stands at £18 billion, up £2.4 billion from March 2005.
By October 2013, the company’s debt stands at £30.611 billion, a rise of £253m since the end of 2012-13. The value of all railway assets stands at £47.933bn.
“The railway continues to experience tremendous growth and we are responding to that demand through our biggest sustained investment programme since Victorian times,” says finance director Patrick Butcher in early winter 2013. “With a million more trains and a half a billion more passengers than ten years ago our railways are all but full.”
Passengers begin to benefit from several large investment projects, notably the £550m renovation and rebuilding of King’s Cross, complete with new and enhanced facilities – and an impressive new concourse that displays sensitivity to the station’s architectural heritage.
Work worth some £850m also continues in 2013 to remove bottlenecks that historically delay trains in and around Reading station. People travelling between northern cities and towns like Manchester, Liverpool, Wigan, Preston and Blackpool expect to benefit from a £400m project to run faster, quieter and cleaner electric trains.
Faster and more reliable train services are promised from the £100m resignalling and modernisation of Nottingham and its approaches in the East Midlands.
Other incremental improvements undertaken by Network Rail include over 2,000 miles of renewed track between 2009 and 2013. Five hundred stations are improved. Over 140 station platforms are lengthened across London and the south-east, the country’s busiest commuter region. Elsenham is just one of a legion of stations now able to accommodate 12-car trains.
Overall, train punctuality performs at high historical levels and monitored passenger satisfaction levels are consistently high. But the overloaded rail network continues to struggle with a lack of capacity. Delays periodically occur – and when they do passengers – already dismayed and angered by above-inflation fare rises and frequently being unable to sit – mutter dismay and anger. Some actively protest through organised passenger groups.
Much of the passengers’ frustration tends to be directed towards the train operating companies over fares. Taxpayers blame politicians for allowing the railways to remain in such a state. Passengers and taxpayers only truly vent their ire on Network Rail when they experience delays, especially during holiday periods.
Fare rises are firmly wedged in 2013 into the wider political row over the ‘cost of living crisis’ where many people in the UK struggle financially. Train operators, along with companies making increased profits from supplying electricity and gas, continue to anger people in the UK struggling to make ends meet, particularly since the banking crisis and financial meltdown of 2007-09.
3. Barratt’s Lane
An elderly woman crossing the railway is struck and killed by a Nottingham-Birmingham train at Barratt’s Lane No.2 footpath crossing at Attenborough, Nottinghamshire, at about 2.50pm on Saturday, 26 October 2013.
The crossing spans two tracks and links two residential areas. Two months later, the RAIB says it will investigate. The RAIB, on 9 December, says: ‘Immediately prior to the accident another train, travelling towards Nottingham, had been stopped at a signal near to the crossing and its presence may have distracted the pedestrian.’
The RAIB says it will also ‘examine Network Rail’s management of the crossing’.
High Street level crossing in Lincoln is one of the most dangerously used crossings. People run across after warnings. Others lift or climb over lowered barriers, often when signallers cannot stop an approaching train. Another crossing at Brayford Wharf East sees similar incidences – and a bridge gains planning approval.
In November 2013, Network Rail submits plans to Lincoln City Council for a new bridge to give pedestrians and cyclists constant access along Lincoln High Street even when trains are passing.
“From our discussion with highways experts, we know it is not possible to close the crossings at this time,” says route managing director Phil Verster.
5. Essex closures
In late November 2013, Network Rail says six level crossings in Essex will be closed and replaced by either a footbridge or an underpass.
Motts Lane near Witham will be closed and replaced by a £2.3m ramped bridleway bridge. A man with a bicycle crossing the two-track railway on a footpath and bridleway crossing was struck and killed by a train at Motts Lane in January 2013. The crossing has a history of wrongful use.
A ramped footbridge will also replace Long Green in Marks Tey. A stepped footbridge will replace Shaw Avenue at Shenfield, where there have been five serious incidents and one near miss since 2007.
Stepped footbridges will also replace Billericay West Park Avenue and Golf Links in Chelmsford. A new pedestrian subway will replace Ingatestone Hall. All crossing replacements should be complete by March 2014.
Route managing director Richard Schofield says: “Where a road, footpath or cycleway meets the railway there will always be a certain level of risk to motorists or pedestrians. Network Rail is committed to reduce that risk as much as possible, so if we can close a level crossing and replace it with an alternative means of crossing the railway, we will.”
6. Bailey Lane
In December 2013, Network Rail seeks permission from Cumbria County Council to permanently close a footpath crossing at Bailey Lane near Grange-over-Sands. A ‘near miss’ occurred in September 2013 when a train travelling at 50mph ‘came within seconds of striking a pedestrian on the crossing’. A three-year-old child died at the crossing in 1988.
Over 4,000 people are recorded using the crossing over nine days in the summer of 2013, including children, cyclists and people using mobility scooters – even though a fully accessible subway providing an alternative to crossing the tracks was built in 2006.
“Network Rail do not want to wait for a tragedy to occur before acting,” says Network Rail area director Martin Frobisher.
7. Union view of cost reduction
Rail unions believe dangerous level crossings could be closed much sooner, and ‘high risk’ crossings phased out earlier, if it were not for the privatised and fragmented structure of the UK’s railways. Unions criticise the ORR for demanding Network Rail reduce the costs of running the railway by almost 20%, or £1.7bn.
Rail, Maritime and Transport general secretary Bob Crow says: “Demanding £1.7bn of cuts from Network Rail threatens jobs, maintenance and safety…If the profits and subsidies sucked out of the railways by the private companies were instead retained within the central pot under one publicly owned rail body, there would be enough money to employ extra staff, tackle the shelved repairs and modernisation works, phase out the lethal level crossings, and increase capacity and reliability.”
8. RSSB research
Forty-nine members of the public are killed on the UK’s railways in 2012-13, according to the Rail Safety and Standards Board. This excludes suicides or suspected suicides. Out of this 49 total, 39 are trespassers on the railways.
Nine of the remaining ten are level crossing users. Four are pedestrians. Five involve road vehicles struck by trains, including four cars and one motorcycle.
The nine deaths in 2012-13 continue an average of nine level crossing user fatalities each year since 2003-04, says the RSSB. Pedestrians make up an average of 7.6 of these annual level crossing fatalities.
Most accidents at level crossings remain caused by ‘user behaviour’ – whether by deliberate violation or error, says the RSSB in its Learning from Operational Experience Annual Report 2012/13, published in the summer of 2013. A small proportion of the risk at level crossings is due to ‘workforce error’ or ‘equipment failure’.
The rail industry commissions the RSSB to conduct further research on the causes of pedestrian accidents at level crossings and to look at potential solutions. This builds on the RSSB’s report, Understanding Human Factors and developing risk reduction solutions for pedestrian crossings at railway stations, issued in January 2009 in response to the RAIB’s report into the Elsenham disaster.
The RSSB states: ‘There has been an average of 7.6 pedestrian fatalities over the past ten years at level crossings in Great Britain. The trend in fatalities over the past decade is fairly flat; the trend in near misses is slightly upwards.’
The research project aims to ‘focus exclusively on what can be done to reduce pedestrian facilities at all types of level crossings’.
The research project, T984, sponsored by the Road Rail Interface Safety Group, aims to sharpen previous RSSB research that has included pedestrian safety at level crossings but has not ‘concentrated exclusively on this large group of users’.
The issue of cost and cost-effectiveness appears, as always. The RSSB hopes the research project will allow the rail industry ‘to determine if there is anything further to be done to reduce risk to pedestrians at level crossings utilising the ‘as low as reasonably practicable’ ALARP principle, and if so, will help to focus the industry’s efforts in the most promising cost-effective areas to reduce risk’.
9. Risk increase of 7%
The ORR reports a mixed picture. The ORR’s Health and Safety Report 2013 says Britain’s mainline railway remains one of the safest in the European Union – ‘…and the best in the EU at managing risks to passengers and at level crossings’.
However, the ORR says although there has been a long-term trend of decreasing risk at level crossings, ‘risk increased by 7% in 2012-12, mostly because of misuse by level crossing users…
‘The small datasets involved make risk analysis difficult but level crossing risk still represents about half of the potential catastrophic train accident risk,’ adds the ORR.
The ORR acknowledges ‘Network Rail is committed to reducing level crossing risk 25% by 2019 and it is currently on-target, as measured by its own model to deliver this. This improvement has come through strong leadership from senior managers and demonstrates what can be achieved with the right focus.’
But, of concern, the ORR warns: ‘We found that in the routes, some level crossing risk assessments were poor and did not identify the best risk controls.
‘We also found that risk assessments were not always carried out at the right stage of the renewal and enhancement process, which introduced delays and additional costs at the level crossing commissioning stage. We note that Network Rail has introduced route level crossing managers and a national level crossing team, which should improve the quality of the risk assessment process.’
Britain’s tramways are some of Europe’s safest, but the death of a pedestrian on the Nottingham tram system in November 2012 prompts the regulator to say: ‘Whilst post-incident reviews often show that lack of attention on the part of pedestrians is normally a root-cause, we recognise that tramway designers and operator could look critically at crossing layouts and tram design.’
10. RAIB on risk increase
The Rail Accident Investigation Branch remains worried by the upward risk trend. The RAIB’s Annual Report 2012, published in 2013, echoes the ORR’s concern about the 7% increase in risk, stating: ‘The two particular areas of risk that we have repeatedly had cause to investigate up to the end of 2012 are level crossing and track worker safety.’
By December 2012, the RAIB completes 39 level crossing accident investigations and makes 160 recommendations.
By autumn 2013, the RAIB is on its 41st investigation and has made 166 recommendations.
‘The number of level crossing accidents and the recently reported increase in related risk continues to be a source of concern to the RAIB,’ says the report.
The RAIB publishes seven reports on level crossing accidents and incidents in 2012. Four are categorised by the rail industry as ‘due to misuse (which includes error, misjudgment or willful misuse)’.
Significantly, the RAIB adds: ‘Our investigations concluded that only one of these involved willful misuse; the others involved human error. ‘In all cases, the RAIB found there were still lessons to be learned by the industry.
‘As a result, we have made recommendations aimed at reducing the industry’s reliance on human performance as the safeguard against a potential fatal accident, and for changes to be made to the design, inspection, and maintenance of the railway equipment and its operation.’
The RAIB also says 24 safety recommendations remain outstanding following eleven level crossing accident investigations that go back to 2005. Seven of those accidents involved fatalities.
11. Safety and profits
Arguments about whether rail safety is compromised by profit extraction rumble on some twenty years after rail privatisation – particularly as the McNulty Report about the rail industry’s future focuses on an overriding goal to drive out costs.
Major fatal accidents decline in the reorganisation era under Network Rail but the Grayrigg derailment in month 2007 – that killed Margaret Masson – focuses attention on the ORR’s preoccupation with so-called ‘efficiencies’ and Network Rail’s actual cost-cutting and management failures.
Rail trade unions go even further and say Network Rail is dragging rail safety back to the worst days of both British Rail and Railtrack. In December 2013, the Rail, Maritime and Transport general secretary Bob Crow says cuts to rail staff – and agencies hiring casual engineering staff on ‘zero hours contracts’ – risks dragging the rail industry back 25 years towards “a culture of fatigue and overwork”.
Crow cites as a marker the disastrous rail clash at Clapham Junction where 35 people were killed and over 100 injured on 12 December 1988. A crowded early morning commuter train from Poole to London Waterloo crashed into the back of another stationary train stopped at a red signal. A third train coming in the opposite direction hit the wreckage a few minutes later.
Anthony Hidden QC’s inquiry into the crash found the primary cause to be wiring errors made by a rail worker who had taken only one day off in 13 weeks. A culture of excessive hours is to blame.
Hidden recommended the maximum staff working period should be 12 hours. Crow says 25 years later that Hidden’s recommendation is now being sidelined and 14-hour ‘door-to-door’ work, including unpaid hours, is commonplace and is “piling on stress and fatigue”.
Crow says: “RMT expects our concerns to be taken seriously and for immediate action to be taken to bring Network Rail works back in house within an environment where safety is paramount and where staff are on decent pay and conditions and where working hours are properly managed and controlled.”
On the Clapham anniversary, Network Rail’s Robin Gisby says: “An awful lot has changed since that tragedy. Signalling systems, training of our staff – the railway is in a completely different place. It is now the safest railway in Europe. But we’re not complacent. There is more we still want to do.”
In November 2013, the ORR says Network Rail underspent on maintenance work and deferred plans to renew infrastructure. Alongside engineering overruns, these factors caused rail passenger and freight train delays between July and October 2013.
The ORR recognises Network Rail is hampered by limitations on how often and long its workforce can gain access to the tracks and infrastructure, largely due to an increasingly busy rail service timetable running on a congested network. But the regulator urges the company to “make good use of the funds provided to renew the network and address the problems affecting performance”.
13. Transparency Panel
In November 2013, Network Rail holds the first meeting of a ‘Transparency Challenge Panel’, part of the company’s avowed aim to increase the transparency of its operations.
The 13-strong panel will meet twice yearly and includes representatives from Passenger Focus, the Cabinet Office, Department for Transport and a rail journalist. Three representatives from Network Rail include outgoing chief executive Sir David Higgins, general counsel Suzanne Wise, and head of transparency Mark Farrow.
“Being truly transparent isn’t just about publishing information,” says Mark Farrow. “The new panel comprises an enormous amount of expertise and I am convinced their input will help us improve our work in this important area.”
PART 18: A ‘sorry’ apology 1. Erroneous use of ‘trespass’ and ‘misuse’ 2. Nine deaths 2012-13 3. Legal representation and bonuses 4. The ‘apology’ 5. “Watershed” 6. Bonuses post-Beccles 7. Families reaction to ‘apology’
A ‘sorry’ apology
It’s Friday, 7 March 2014.
Apparently, not a day for pulling punches.
Members of Parliament on the House of Commons Transport Select Committee hit out hard at Network Rail.
They say Network Rail ‘must apologise for the way the company has handled past level crossing tragedies’.
MPs also say Network Rail and the Office of Rail Regulation should ‘aim to cut fatalities at level crossings to zero by 2020’.
The MPs’ report makes 25 recommendations, ten of which specifically call on Network Rail to act.
1. Erroneous use of ‘trespass’ and ‘misuse’
Louise Ellman MP, chair of the Transport Committee, launching the committee’s report on safety at level crossings, says: “Victims were erroneously described as ‘trespassers’ or accused of ‘misuse’ of the railway when, in fact, they tried to use level crossings appropriately.
The report says the rail industry, Government and Office of Rail Regulation should stop using the term ‘misuse’ in relation to accidents at level crossings and instead adopt ‘deliberate misuse’ where the evidence supports this and ‘accident’ where it does not.
“A lack of transparency around safety concerns at the Elsenham crossing was particularly shocking and raises profound questions about Network Rail’s internal culture and accountability,” adds Ellman.
Committee MPs, in their report, Safety at Level Crossings, state: ‘Network Rail should disclose to the bereaved families from the tragedy at Elsenham the findings of all investigations into why ‘Part B’ of the risk assessment, the ‘Hudd Memo’ and the Health and Safety Executive report on Network Rail’s risk assessment methodology were not initially disclosed.’
The MPs note the existence of both Part B of the Elsenham risk assessment and the Hudd memo only came to light when disclosed in 2010 by a Network Rail employee.
The report says:
“It is unlikely that Network Rail would have been prosecuted in relation to the Elsenham tragedy were it not for the actions of a whistleblower. The knock-on effects of the successful prosecution encouraged Network Rail to take level crossing safety much more seriously.”
2. Nine deaths 2012-13
Ellman continues: “Network Rail has lowered the risk of death at a level crossing by 25% since 2008, but when suicides and trespass are excluded, level crossings still account for one half of all fatalities on the railway in recent years including nine people who died in 2012-13.
“Every one of those deaths was a personal tragedy which could have been averted,” says Ellman. “Yet looking back it’s clear that on too many occasions Network Rail showed a callous disregard for the feelings of families of people killed or seriously injured in accidents at level crossings.”
Ellman also says Transport Committee MPs are calling on the government to consider whether Network Rail and its employees should be subject under licence to a ‘duty of openness, candour and transparency’, similar to recommendations made by the Francis Inquiry into the Mid Staffordshire NHS Foundation Trust.
3. Legal representation and bonuses
The MP for Liverpool Riverside also states: “Network Rail should also consider what level of legal representation is appropriate at inquests, taking care to ensure bereaved families are not left feeling disadvantaged.
On Network Rail executive bonuses, Ellman concludes: “Given that Network Rail has recently been held responsible for the serious accident at Beccles in July 2010, we do not believe executive directors should get any bonuses this year.”
4. The ‘apology’
Mark Carne’s first major public task as Network Rail chief executive is to issue an apology over the way the publicly-funded company – under his predecessors – has treated bereaved families of people killed at level crossings.
Carne says: “Today, I wish to extend a full and unreserved apology on behalf of Network Rail to all those whose lives have been touched by a failing, however large or small, made by this company in managing public safety at level crossings and in failing to deal sensitively with the families affected.
“Nothing we can say or do will lessen the pain felt by the families of those killed or injured at a level crossing. Today Network Rail is a very different company to the one which existed at the time of these tragic accidents.
Carne uses the term “watershed”, as used by Robin Gisby when trying to impress upon MPs that the company has transformed its internal culture on managing level crossing safety.
Carne says: “As we made clear when we pleaded guilty during the Elsenham court proceedings, it was a watershed in the way we thought about our approach to the risk at level crossings, and how we treat victims and their families.
“As a result of this transformation, level crossings in Britain are amongst the safest in Europe, but there is still much that we can, and will, do and the committee’s recommendations will help us in that endeavour.”
Carne continues: “The way Network Rail now manages level crossings has fundamentally improved, with investment totalling £130m over the last five years helping us to close almost 800 crossings and reducing the level of risk across the network by more than a quarter.
“This progress is welcome, but we will never be complacent when it comes to public safety. As I start my term as chief executive I have made improving public, passenger and workforce safety absolutely integral to everything Network Rail does.
“There is much more we can do to make the level crossings that remain safer and we will continue to introduce new technology, upgrade crossings to include lights or barriers where appropriate and work with schools, communities and other organisations to spread awareness of our safety message.
“We have agreed funding of more than £100m with the regulator to continue this work over the coming five years as we work tirelessly across the network to make our railways safer.
“Restoring public trust relies on openness and with that in mind we made risk assessment information relating to almost all our 6,300 crossings available on our website. I will continue to explore ways to make our processes even more transparent so we can demonstrate clearly that we treat our responsibility for ensuring public safety with the utmost professionalism.”
6. Bonuses post-Beccles
On Network Rail executive bonuses, committee chairman Louise Ellman MP says: “Given that Network Rail has recently been held responsible for the serious accident at Beccles in July 2010, we do not believe executive directors should get any bonuses this year.”
A ten-year-old boy suffered life-changing injuries in a collision between a train and a car at level crossing near Beccles in Suffolk in July 2010. An investigation by the Office of Rail Regulation found that Network Rail had failed over ten years to act on information about poor visibility of approaching trains.
In March 2013, Network Rail pleaded guilty to breaches of health and safety law and was later fined £500,000.
Richard Parry-Jones, chairman of Network Rail, says on 7 March 2014, Network Rail’s Board, via its “independent remuneration committee” formed entirely of non-executive directors, will consider the MPs’ recommendations on bonuses.
The company says annual bonuses for executive directors have either been scaled down or foregone completely in some years between 2010 and 2014, often reflecting level crossing safety concerns.
7. Family reaction to ‘ apology’
Reg Thompson, father of 13-year-old Charlotte Thompson, describes Network Rail’s apology as “utterly meaningless”.
“We didn’t hear anything at all from Network Rail for five and a half months after the accident,” recalls Thompson.
“Whereas we received support and messages of real compassion from the train companies, Central Trains and ‘one’ Railway.
“Network Rail did nothing, said nothing,” adds Thompson. “Eventually we received a kind of standard letter from the then chief executive John Armitt, who said ‘we’re sorry for your loss’, and that was that.
“The company then went on to protest its complete innocence for a number of years, saying it played no part in the deaths of my daughter Charlie and her friend Liv.
“Only after the well-publicised court case in March 2012 when Network Rail was found guilty of breach of health and safety and negligence and incompetence in the deaths of our daughters- and was fined one million pounds – did the then chief executive Sir David Higgins personally say he was sorry.
“But the company has never apologised.”
As for the apology on 7 March from the new chief executive Mark Carne, Thompson says: “I very much hope that Mark Carne is a decent and serious human being – and I appreciate what he is trying to do.
“But to have an apology eight years and three months after the accident – that had only come forth because a Transport Select Committee report has been utterly damning of Network Rail’s behaviour and forced them to do so – is not a real apology.
“An apology is important.
“To have said ‘sorry’ after the accident would have meant something.
“But now, and within this context, it’s utterly meaningless.”
PART 19: An Elsenham legacy 1. A legacy of injustice 2. A safety legacy 3. Motts Lane 4. Structural rail industry causes 5. The future 6. Near misses continue
An Elsenham legacy
When the phrase ‘tragic accident’ is used to describe a death, the commonly held assumption is that no individuals or an organisation can be faulted or held legally responsible for an unfortunate sequence of events.
The railway regulator and rail safety and accident bodies investigate the Elsenham fatalities. They each decide, on the basis of the available evidence, that no individual or organisation can be found negligent or guilty of a criminal act that led to the deaths of Olivia Bazlinton and Charlotte Thompson.
On the basis of this available evidence, a coroner’s inquest also decides the Elsenham fatalities were accidental deaths.
An initial common narrative frames the Elsenham fatalities as a tragic accident. Two young people tragically lose their lives. Two families suffer heartbreak and grief. Many friends mourn.
Senior Network Rail officials and route management staff express the company’s corporate condolences to the grieving families.
Network Rail says the girls died tragically after mistakenly crossing against warning lights and an alarm. The company says the station footpath crossing is safe, if used correctly. The gates will remain unlocked and there will be no footbridge.
But soon an RAIB investigation discovers flaws in Network Rail’s management and mitigation of risk at Elsenham. The company reverses its original stance that the crossing is entirely safe and there will be no locking gates or footbridge.
Locking gates are installed that interlock with signalling. A footbridge is also installed.
The train operator installs a ticket machine on the Down platform.
Yet Network Rail persists with the line that these measures only make an already safe crossing, even safer.
However, during 2010/11 – over five years after the fatalities – it emerges Network Rail had known all along that Elsenham station footpath crossing was dangerous.
Four years before the tragedy, John Hudd warns management: ‘The risk of disaster is real.’ Younger people are at considerable risk, adds Hudd, due to the large numbers of school pupils and college students who use the crossing.
Three years before the disaster, Trevor Hill recommends the installation of locking gates should be considered.
Hudd and Hill write and record their anxieties in official Network Rail documents.
But Network Rail’s Anglia route management and the company’s executive managers fail to act on these warnings and predictions. No action is taken to reduce risks – and then the risk of disaster becomes a terrible reality when Olivia and Charlotte are sadly killed at the crossing on that Saturday morning, 3 December 2005.
After the fatalities, Network Rail appears to compound this failure to act with at best, sheer incompetence, or at worst, a deliberate cover-up. Either way, the company fails to provide the Hudd and Hill documents to accident investigators appointed by the government on behalf of taxpayers and the wider British public to discover the immediate and underlying causes of the fatalities.
This non-disclosure deprives a coroner and her inquest jury of vital pieces of evidence to consider when officially and publicly determining the immediate and underlying causes of the deaths of Olivia Bazlinton and Charlotte Thompson. Hudd and Hill, for instance, do not give evidence.
Later, this non-disclosure also further undermines the legal process, when members of the girls’ families bring civil cases against Network Rail.
One other investigating body, the Railway Safety and Standards Board, core-funded by private railway industry companies and by government, is apparently aware of at least one of the documents, Hill’s Part B. However, for reasons as yet unknown, the RSSB does not refer to it in its 2006 report on Elsenham.
Instead, the RSSB focuses on classifying ‘misuse’ of level crossings as intentional, unintentional, and impulsive.
Network Rail does not disclose the documents. Worryingly, the existence of the Hudd and Hill documents only comes to light through a ‘whistleblower’ within Network Rail. The girls’ families learn of the existence of the documents via the whistleblower and an official from her trade union.
One document is first discovered by Tina Hughes, Olivia’s mother, as she is about to put a set of legal documents in a loft following the settlement by Network Rail of her civil case against the company. Later, the other document ‘appears’ just as the ORR is about to go through a set of papers at Network Rail’s offices.
The common narrative now changes dramatically. Publicly aired allegations focus on a small number of individuals within Network Rail. Did they know Elsenham station footpath crossing was dangerous but failed to act to make it safe?
After the unofficial disclosure of the Hudd and Hill documents, the Office of Rail Regulation re-opens its closed investigation and then decides to prosecute Network Rail for breaches of health and safety law, that include a failure to properly assess, manage and mitigate risk at Elsenham..
Network Rail pleads guilty.
The company is fined £1 million.
Taxpayers, including the families of Oliva Bazlinton and Charlotte Thompson, will ultimately pay this penalty.
1. A legacy of injustice
So far, no precise and coherent explanation has emanated from Network Rail about why its relevant managers failed to act upon Hudd’s warnings and Hill’s recommendation about Elsenham in the period between May 2001 and December 2005.
Similarly, no precise and coherent explanation has emanated from Network Rail about why it failed, unwittingly or deliberately, to disclose the Hudd and Hill documents to officially appointed bodies after the fatalities.
During its re-opened investigation, the ORR questions individual Network Rail staff under caution but cannot find sufficient evidence of deliberate non-disclosure by any employee.
No individual is charged.
Nobody is held accountable.
To borrow from the RSSB’s lexicon, was the ‘non-disclosure’ of the Hudd and Hill documents intentional, unintentional or impulsive?
Unintentional non-disclosure would suggest individuals within Network Rail temporarily misplaced or forgot about the documents. This would represent sheer incompetence and a lack of care towards an important rail safety matter.
Impulsive and/or intentional non-disclosure suggests individuals within the company deliberately concealed the documents and failed to mention their existence after the tragedy. This would constitute a ‘cover-up’.
If so, in whose interests were served by concealment? Possible motives might include the wish of individuals to avoid being asked why they did not make Elsenham safer sooner – and/or a desire for the company to avoid a corporate prosecution.
To tar all of Network Rail’s thousands of hardworking and dedicated managers and frontline staff with a ‘cover-up’ allegation would itself be grossly unjust.
But institutional questions about Network Rail’s corporate malfeasance over Elsenham are still being asked. Are certain individuals who knew about the risks at the crossing – but took no action – still working within the rail industry?
Will anyone be brought to justice for carelessly or deliberately perverting the course of a coroner’s inquest and civil legal proceedings? Will anyone ever be held accountable for denying officially appointed rail accident investigators access to information about the underlying causes of the tragedy?
Will the injustice of failing to make a dangerous crossing safe, compounded by the non-disclosure of Hudd and Hill, ever be righted?
One part of the legacy of Elsenham is that taxpayers, rail passengers and the wider public might never know the truth about Elsenham – unless new information comes to light.
Can Network Rail ever be ‘open, transparent, accountable and responsive’, as outgoing chief executive David Higgins heralded when he first took over?
The company tries to convince MPs that Elsenham was a “watershed” that led the company to transform the way it managed level crossing safety. But this “watershed” is only reached after a whistleblower reveals the existence of the Hudd and Hill documents.
Network Rail issues an ‘apology’ to the families only over eight years after the accident – and only after MPs say the company ‘must apologise’.
Other questions persist. British Transport Police officers are said to have visited Olivia and Charlotte’s school at Newport, just north of Elsenham, earlier in 2005. But did Network Rail forearm the BTP officers with the kind of observations made by Hudd and Hill, so that the officers could have properly forewarned young people at the school?
Why was a private train operating company allowed to run a station with ticket sales points only available on one side of the railway?
Furthermore, in December 2005, Elsenham is included in a list of crossings for review. Safety Management Information System data shows three ‘near misses’, occurring in March 2004, July 2005 and November 2005. These ought to trigger an early review but this does not happen.
Chris Bazlinton, Olivia’s father, says: “I do not believe we that we have heard the full story of what happened at Elsenham or subsequent accidents. As far as we know, there have been no internal inquiries to analyse what happened, who was responsible and how mistakes can be avoided in future.
“As far as we know, there have been no internal inquiries to analyse why safety assessments were not completed properly or why warnings by officials were not heeded or followed up. In some ways, the events suggest more of a conspiracy of silence.
“Unless there is true accountability, and analysis of systems and failings when accidents occur, it is likely that the mistakes will be repeated.”
Elsenham is now a safe crossing. It’s got locking gates. It’s got a bridge.
“But for too long Network Rail said about Elsenham that they wanted to make a safe crossing even safer. But they had the evidence that Elsenham was not a safe crossing. So they lied.”
Bazlinton adds: “I want people to realise that Charlie and Liv would be alive today if Elsenham station level crossing had proper safety in place.
“You never forget what happened for a single day. Every single day, you think about it.”
Reg Thompson, Charlotte’s father says: “I think Network Rail has behaved appallingly badly and without honour. They’ve been forced to admit what they knew all along…Personally, I will take further action if it is revealed that Network Rail acted criminally in knowledgeably withholding information.
“The people who are responsible for what happened to Liv and Charlie probably still sleep at night…If Network Rail had behaved with any integrity, they wouldn’t have put us through six years of constantly being brought back to the moment of what happened to Charlie and Liv.”
2. A safety legacy
The heartbreak of the Elsenham disaster can never be mended.
However, a significant degree of improved level crossing safety across the UK could be an enduring Elsenham legacy.
Certainly, Network Rail is keen to identify this as a legacy and trumpet some early achievements.
Network Rail acknowledges the deaths of the two girls at Elsenham marks a fundamental ‘watershed’ in level crossing risk assessment, mitigation and management. The families of Olivia and Charlotte say the fatalities were not the ‘watershed’. The ‘seismic’ positive shift in Network Rail’s approach to level crossing safety came only after a whistleblower revealed that the company had concealed documents that showed it knew Elsenham level crossing was highly dangerous.
Since 2005, new systems have been put in place – and dangerous crossings closed; although some tragically again too late, as highlighted by the death of Katie Littlewood at the subsequently closed Johnson’s Crossing.
Network Rail still owns and operates over thousands of level crossings, including some 4,000 with public rights of way and 1,500 that allow road traffic. Level crossings are generally safe, claims Network Rail and the Rail Standards and Safety Board, the industry’s safety research body. UK crossings are second only to Norway in terms of safety, according to the Eurorail agency.
In January 2014, Network Rail announces the closure of Cardells level crossing in St Neots on the East Coast Main Line in Cambridgeshire. Network Rail claims the closure means the company has now reached a target, set in 2010, of closing 750, or 10%, of Britain’s level crossings by April 2014.
The company says these 750 closures contribute towards a 25% reduction in the risks posed by level crossings on the UK rail network.
It takes stock of its £131m national level crossings improvement programme that began in 2010. By the end of March 2014, says the company, 38 footbridges will have replaced crossings. Fifty-seven new spoken warnings will be installed to announce ‘another train is coming’ when one train has already passed through.
Obstacle detection radar technology will be installed at 13 sites. New warning lights will be in place at 16 crossings.
New barriers will be installed at 33 sites with formerly open crossings. Some 250 power operated gate openers will be installed to stop vehicle owners crossing the tracks on foot unnecessarily or prevent gates being left open.
‘Wavetrain’ sound vibration technology will be trialled at Whitehouse Priory View crossing in Norfolk.
This adds to the GPS technology installed on the Marks Tey-Sudbury line that allows signallers to precisely locate a train’s position and so provide better safety information to people requesting to cross.
It adds to the 100 level crossing managers and the 13 mobile safety ‘camera enforcement vans’ operated by British Transport Police.
Network Rail pledges to close another 500 crossings up to 2019 at a cost of over £100m.
This ring-fenced money gives Network Rail a golden opportunity to prevent level crossing incidents, accidents and disasters. The appointment of over 100 level crossing managers ought to embed an improved level crossing safety culture within Network Rail.
Kate Snowden, head of media campaigns at Network Rail, says in January 2014: “The safest crossing is a closed one. So local authorities, residents, local rail groups, we need your help to close as many crossings as we can and make it safe for everyone using the railway.”
Network Rail’s determination to close level crossings represents a complete reversal from its pre-Hudd and Hill position when it persisted with the line that crossings were generally safe if people exercised personal responsibility when using them.
Chris Bazlinton accepts there has been considerable improvement in Network Rail’s approach to level crossing safety since David Higgins started as chief executive in February 2011.
“Safety assessments have improved, but there has been too much reliance on rigid statistical methods, as witnessed by faulty assessments at Elsenham on a number of occasions,” says Bazlinton.
“I believe greater reliance on common sense would improve matters; in both cases where the true dangers were revealed, by Hudd and Hill, it was down to basic observation, not mathematical formulae,” adds Bazlinton.
However, he points out there is further evidence from the ORR of internal failures at Network Rail in 2007-08 which “meant no action was taken to build a bridge across another crossing not far from Elsenham where there was a fatal accident in 2012” (Katie Littlewood, 15, at Johnson’s Crossing, Hertfordshire).
Managing director of network operations Robin Gisby, who has been at Network Rail throughout the entire Elsenham episode, says: “Britain’s railway is safer than ever before, but even so there will always be a certain level of risk to motorists or pedestrians where a road, footpath or cycleway crosses the tracks. Network Rail is committed to reduce that risk as much as possible and if we are able to close a level crossing, we will.”
Gisby also claims Britain has Europe’s safest railway. However, specifically in relation to improving level crossing safety, it might be noted that Britain lags behind other European countries. In the Netherlands, for example, a yearly additional railway safety budget of €29.5m was earmarked for improving level crossing safety between 2001 and 2004.
In addition, a one-off €113.4m budget was allocated to upgrade existing level crossings and replace many with bridges. Another €194m was provided between 2005 and 2009 to replace all automatic open crossings, a type of crossing that posed specific safety risks across the Netherlands.
However, level crossing fatality figures suggest an improving downward trend in the UK. In 2008-09, ten pedestrians are struck and killed by trains at level crossings. In 2009-10, eight people are struck and killed.
In 2010-11, four people are killed. In 2011-12, three are killed in this way. In 2012-13, four pedestrians are struck and killed by trains at level crossings.
It would be foolish to underestimate how much of this improvement in level crossing safety is driven by the determination of the families of Olivia Bazlinton and Charlotte Thompson to discover the truth behind the Elsenham tragedy.
In particular, Network Rail acknowledge much of this improvement is also due to the tireless energy and applied expertise of Tina Hughes, Olivia’s mother, in her work with the company as a ‘level crossing safety champion’. Carne meets Hughes and wants her to carry on helping the company change its level crossing safety culture.
However, Hughes worries in 2013 that senior management undervalue frontline Network Rail staff. “The last two years have seen significant progress but it’s vital for public safety that this work continues,” says Hughes.
Hughes questions the suitability of automatic half barrier crossings, like Cherry Willingham, where they are close to stations or schools. Hughes says pedestrians on the side of the road with no barrier can easily walk or run around the side with the barrier if late for a train, a risky action.
And, the fatality figures for 2013 seem to underscore the ‘complacency’ issue, especially when it comes to ‘unintentional misuse’ through a misunderstanding of the crossing operation.
In 2013, ten people die in level crossing accidents. Trains and road vehicles collide ten times. CCTV footage from train cabs shows several near misses involving motorists, cyclists and pedestrians.
3. Motts Lane fatality
One of those fatalities concerns the death of a cyclist at a level crossing on 24 January 2013. The cyclist used the footpath and bridleway crossing at Motts Lane at Witham in Essex and was struck and fatally injured by a passenger train travelling at almost 100mph (160 kilometres per hour).
In darkness at 1737, red lights indicated the approach of trains. The associated audible alarm warning was sounding. The RAIB says the cyclist was ‘unaware that the train was so close to the crossing, probably because it was difficult to pick out the train’s headlight amongst the lights of Witham station, about 700 metres from the crossing’.
The cyclist rode onto the crossing into the path of the train, even though the lights showed red. The RAIB says: ‘Although it is not possible to know why he did this, it may have been because he was used to seeing the lights at red for long periods before trains arrived at the crossing, and decided for himself whether it was safe to cross.
‘The lights showed red for long periods because there were deficiencies in the design of the railway signalling system in the area, and it was not being used as it was designed to be.’
The RAIB recommends Network Rail review and reduce long waiting times at such level crossings and to modify its risk management processes for such crossings.
It also asks Network Rail to minimise local variations in the way trains are signalled that may affect the length of time that red lights show at crossings.
Motts Lane shows Network Rail cannot afford to be complacent and work still needs to be done.
4. Structural rail industry causes
Can any of the immediate and underlying causes of the Elsenham rail disaster of December 2005 be linked to the changing and disrupted structure, ownership and management of the UK’s railway industry?
Some underlying causes of the deaths of Olivia Bazlinton and Charlotte Thompson can be traced back to each period – nationalisation, privatisation and re-organisation – and to the failings of British Rail, Railtrack and Network Rail.
British Rail suffered from government underinvestment and self-imposed cost-cutting that compromised safety. The failure to implement proposals for a ‘second train coming’ audible warning at Elsenham following the 1989 level crossing fatality may have been one such instance.
Railtrack’s performance was measured in terms of factors such as train punctuality and cancellations – but not safety. Indeed, Railtrack and private rail companies stood accused of putting performance and profits ahead of safety. Certainly, Railtrack did not prioritise level crossing safety, despite the publication of new standards.
Network Rail replaced Railtrack and was tasked with improving rail safety after Railtrack’s catastrophic management failings and lax interfaces with private contractors. But Network Rail also failed to manage, mitigate and eliminate risks at Elsenham.
A lack of action by senior management following recommendations, warnings and agreements by frontline staff – and a lack of transparency and accountability – thread their way through each Elsenham chapter.
5. The future
Robin Gisby, who held a senior operational position in Network Rail in December 2005, tells MPs in November 2013 that Elsenham remains “a watershed” in the way the company approaches level crossing safety – and the ring-fenced funds to close hundreds of crossings permanently suggests the company has completely reversed its corporate attitude, policy and practice.
Demand for rail travel in the UK is likely to remain stable and increase – despite much comment in 2014 of rail fares possibly hitting ‘an affordable ceiling’. Stable and increasing demand places constant pressure on Network Rail to assess and manage railway safety, including mitigating risk at level crossings.
A longer-term anxiety exists. Calls to drive through a cost-reduction reform of Network Rail could risk creating upheavals and compromises similar to those that previously led to British Rail, Railtrack and Network Rail taking a complacent and even negligent approach to level crossing safety. Ongoing ring-fenced funds, specialist staffing and applied research and technology can mitigate this risk of a pendulum effect where level crossing risk increases once more.
Many observers are encouraged by Network Rail reducing the rail industry’s reliance on human performance as the safeguard against potential fatal accidents. Instead, the company seems to focus the industry more on increasing the safety of trains, tracks, signalling and protecting users at level crossings.
However, proposed level crossing closures have provoked opposition in some instances. Network Rail is accused by some people of using closures to absolve itself of a problem and of displacing risk from the railway to the roads. Critics point out Network Rail does not properly assess risks off the railway when proposing a level crossing closure.
But what should the company do? It will be damned if it persists with a dangerous crossing where risk cannot be adequately mitigated. It will also be damned if it closes a dangerous crossing and forces people to use an alternative, and a possibly longer and also risky, route to cross the railway.
Of course, overall progress on level crossing safety fits the historical pattern of disaster acting as the catalyst for safety measures. A significant core of level crossing safety progress is generated by the moral pressure imposed by the December 2005 fatalities.
This progress is compelled by a moral outcry over Network Rail’s failure to act on prior warnings about Elsenham station’s footpath crossing. Progress is further compelled by the company being exposed by a whistleblower for its subsequent non-disclosure of these warnings.
6. Near misses continue
The ice has thickened; but still poses considerable risks.
On 21 January 2014, Tina Hughes, Olivia’s mother, warns level crossings remain inherently dangerous. “If you’re hit with a glancing blow, you might get away with losing an arm or a leg. But if you get hit, you’ve had it really.
“For me, the most terrible thing was the fact that my daughter died that day and I never got to see her again or hold her, because it is such a catastrophic way to be killed.”
A day later, Hughes talks with school pupils about level crossing safety at Cherry Willingham Community School in Lincolnshire. Head of Year 11 Craig Brewer says he invited Network Rail and Tina Hughes to talk to pupils “because I was increasingly concerned about level crossing safety in the village, following three near misses in recent weeks”.
Staff and students listen to Hughes in a special school assembly. Hughes says: “I hope the pupils will think about how devastating it would be for their parents, families and friends if they were killed and realise that a two-and-a-half minute wait to cross the tracks is just not worth risking their life over.”
The three ‘near misses’ reportedly occurred at the nearby Cherry Willingham level crossing in Lincoln.
Phil Verster, Network Rail route managing director, says 231 crossings have been closed on rail routes that go through eastern England. But he adds 2,199 level crossings still operate on eastern England routes, including Elsenham.
PART 20: Elsenham Postscript
It is 10.30am on 7 December 2013, one of those relaxed Saturday mornings that older children appreciate and enjoy, especially after a week of teachers, homework and school.
As the first Saturday of December, Christmas seems just around the corner. In the past week, Elsenham station has bristled with determined commuters. Today, the platforms breathe more easily.
Weak sunlight tries to break through a thick moving clump of grey clouds. Light rainfall sheens the surface of the road level crossing. The number ‘7’ bus crosses from Station Road and disappears around the curving Old Mead Road on its way to Stansted Airport.
Three women walk towards the road crossing together. Each is walking a dog on a leash. They nonchalantly cross the railway tracks by using the road vehicle crossing.
A cool, stiffening breeze lightly rustles clear plastic covers that protect thirteen small bunches of fresh flowers. The flower bunches lay on a verge of grass, clover and fallen autumn leaves near the white picket fence between Station Road and the railway.
A bunch of roses is taped to one of two aluminum posts that support a road sign that says ‘STATION ROAD’. Dappled with raindrops, the flower bunches include pink, yellow and cream roses and hot pink carnations. Each bunch is bow tied at one end with a pink or blue ribbon.
Handwritten messages on cards attached to the flower bunches include:
‘Charlie. Know that you dance around your Mum as I see you in my dreams.’
‘Liv. The years pass but memories never fade’.
A photograph of Olivia Bazlinton with a birthday cake printed onto an A4 sheet of paper is taped to the white picket fence. The photo is headed ‘Olivia’. Underneath the photo, it reads:
‘8 years on…always
Dad, Nicki and family xx
3 December, 2013’
It’s now over eight years since Olivia Bazlinton and Charlotte Thompson were killed after being struck by a train on Elsenham station’s footpath level crossing on Saturday morning, 3 December 2005.
In those eight years, the ebb and flow of trains and passengers at Elsenham has changed little. The 0928 hours Greater Anglia London Liverpool Street to Cambridge service glides over the station’s road and footpath crossings and halts at the Down platform at 1021.
Private train operating company, Abellio, part of Abellio Transport Holdings, a Dutch-owned transport group, runs the 1022 from Elsenham. The Department for Transport awarded the Greater Anglia franchise to Abellio to run train services on the West Anglia Main Line until July 2014.
The train pulls away from Platform 2 on its way north to Cambridge. A Network Rail crossing keeper emerges from his cabin at the end of Platform 1 and opens the road crossing gates to vehicles.
The flowers lie just a few yards from the Down line pedestrian gate that guards the footpath crossing over the railway tracks.
A young man and woman open the Down line pedestrian gate and use the footpath crossing to walk over the railway and through the Up line gate to reach Platform 1.
Just a few days after the December 2005 disaster, Christian Wolmar, one of Britain’s leading transport commentators and historians, visited Elsenham and wrote: ‘The whole feel of the crossing was something out of the Railway Children film, perfectly suitable for a branch line with a few trains per day, but not for a busy line with up to eight trains an hour including freight…
‘Just one glance at the crossing with its badly painted wobbly line on the tracks and the cute little latch-less wicket gate, which offers no hint of the dangers posed by the location, should be enough to make any concerned railway manager gasp in disbelief…The principle of making risk ‘as low as reasonably possible’ seems not to have been applied sensibly here. I suspect there will be major changes at Elsenham, too late for the two girls.’
Eight years on, Elsenham station still looks like a branch line station. The station’s ‘road-rail interface’ keeps the level crossing keeper very busy each hour opening and closing the road crossing gates. Stopping and non-stopping passenger services and freight trains continue to pass over the station’s road and footpath crossings.
A steady stream of cars, buses and vans idle behind the closed road crossing gates. An irregular trickle of pedestrians and intending passengers walk across the tracks when the road and pedestrian gates are unlocked.
But major changes – eventually – have altered Elsenham station and the operation of its ‘interface’ between trains, vehicles and pedestrians/intending passengers. Of course, these changes are ‘too late for the girls’, as Wolmar predicted on 21 December 2005 – and, albeit belatedly, the principle of making risk ‘as low as reasonably possible’ seems to have been applied sensibly here.
The footpath crossing gates and their operation have changed almost completely since December 2005. There is still a significant recess between each gate and the tracks.
However, the ‘cute little’ white pedestrian wooden picket gates have been replaced by matt black metal gates, made up of 15 cylindrical bars welded to a square frame that also supports a large handle.
Unlike in December 2005, Elsenham station’s footpath crossing pedestrian gates now lock. Moreover, they now ‘interlock’ with train signalling.
This crucial risk mitigation measure renders these heavier, rounded spike-topped gates completely different from the lightweight, non-locking footpath crossing wicket gates that footpath crossing users, including Olivia Bazlinton and Charlotte Thompson, operated and freely opened in 2005.
‘Interlocking’, within the Elsenham level crossing context, means a signal for a train to proceed towards the station cannot be released and displayed until the road and footpath level crossing gates are both locked. In December 2005, the road gates locked but not the footpath crossing gates.
But now, in December 2013, both road and footpath gates interlock with signalling, ‘protecting’ the railway from both vehicular and pedestrian encroachment. Therefore, there is little risk of trains ‘mixing’ with vehicles, pedestrians and intending passengers – only unless a vehicle driver crashes through the full road barriers at high speed, or a pedestrian deliberately climbs over the locked gates and jumps onto the railway.
In railway industry terms, the changes upgrade Elsenham station so it provides a keeper-operated, signal interlocked, full barrier, vehicular level crossing. This crossing operates in tandem with an adjacent and parallel keeper-operated, signal interlocked, station footpath crossing. Rail passengers, trains, vehicles, and now pedestrians and intending passengers benefit from considerably more protection than in 2005.
Cambridge Power Signal Box still controls the signalling between Cambridge and Stansted. But signallers can now interlock the signalling with the road and footpath crossing gates at Elsenham.
The signals are still Track Circuit Block, a system that detects trains within a section of signalled track and so helps to keep trains a safe distance apart.
The railway line is divided into blocks. Each block is protected by a signal at its entrance. Train drivers respond accordingly to a stop or go indication.
A signal is only cleared for a train to actually begin its approach to the station when the level crossing keeper locks the road crossing and the footpath crossing gates.
If the keeper does not manually lock the footpath crossing gates via his control panel in his cabin then the signal will not be cleared for the train to approach.
The now enhanced sequence that closes both the station footpath and vehicular crossings begins with the sound of the bell. The level crossing keeper closes the two vehicle crossing gates in order to close the crossing to road vehicles but clear the railway for trains.
The keeper takes a key from each of the two road vehicle crossing posts. He returns to his cabin. He inserts the road crossing gate keys into his control panel.
The keeper manually locks the station footpath crossing gates.
Both road and footpath crossings are now fully protected by locked road barriers and footpath pedestrian gates. Trains can now proceed.
Pedestrians can still cross the tracks between platforms – via the footbridge.
No more MWLs and alarms
In December 2013, unlike December 2005, the footpath crossing is no longer protected by miniature warning lights or by audible yodel alarms.
Locking pedestrian gates – locked manually by the crossing keeper – mitigate risks to footpath crossing users.
Crossing users are also protected by the footbridge and by automated voice warnings relating to trains approaching on both Up and Down lines.
Fixed to the fence by the gates, a large luminous rectangular sign with red capital letters states:
Bells signal another approaching train. The crossing keeper closes the road crossing gates again. People wait on Platform 1 for a stopping Up line train.
The keeper goes inside his cabin. The metal footpath crossing gate on the side of the Down line is now firmly locked.
Greater Anglia 379 030 passes over the station’s road and footpath crossings with the 1021 Cambridge to London Liverpool Street service. The train stops at Platform 1.
The level crossing keeper opens the road crossing gates to vehicles behind the train still at Platform 1. At the same time a middle-aged woman opens the footpath crossing gate and uses the footpath crossing behind the train that now begins to depart from Platform 1.
At 1025 another bell rings for one minute and five seconds. The crossing keeper comes out of his cabin again and closes the two vehicular crossing gates. A man comes out of T.J Poppins, the small corner shop at the southern end of the Down platform. He carries a newspaper and reads some notices on the shop window.
Yellow metal notices on lampposts on the Platform state: ‘For your own safety. Always remain behind the yellow line until your intended train has stopped.’
After the bell has stopped ringing, an automated audio warning can be heard coming through the station’s loudspeakers: ‘The train now approaching Platform One does not stop here. Please stand well clear of the edge of Platform One.’
Seven seconds later, a fast express train emerges around the track curvature at Elsenham. Less than three seconds later, the train races over the crossing. It thunders a few feet past the open edge of Platform One and disappears southward.
The crossing keeper re-emerges and opens the road crossing gates so queuing vehicles can cross the railway once again.
A thick horizontal concrete base anchors the footbridge. Concrete and metal pillars and elevate the metal footbridge – numbered ‘1501’ – over the station and railway. Five sets of stairs lead up to the metal footbridge on each side of the tracks.
The bridge allows passengers to cross the railway line between the Station Road side of the station and the Up Platform. The uncovered bridge span is on one level and is enclosed with high-sided panels. Lights illuminate the bridge crossing. Passenger jets can be seen from the bridge across the undulating fields to the east of the station on their final approach to nearby Stansted Airport.
At 1030 the bell sounds once more. The crossing keeper comes out and begins closing the gates. After 28 seconds a second bell sounds, adding a harmonic to the first bell.
The road crossing gates are closed. At 1031 and 50 seconds the bells cease. Vehicles begin to queue behind the closed road gates on either side of the crossing. An audible automated voice warning states: ‘The train now approaching Platform One will not stop here. Please stand well clear of the edge of Platform One.’ In the distance, a train horn sounds.
Almost instantly, another voice message sounds a warning of a second approaching train: ‘The train now approaching Platform Two does not stop here. Please stand well clear of the edge of Platform Two.’
As soon as this warning ends, a non-stopping Cross Country service, a Class 170 two-car diesel-powered multiple unit, hauled by 170397, passes over the crossing, passes Platform 1 and heads away south along the Up line (below).
Thirty seconds later another non-stopping Class 170 two-car Cross Country service passes over the crossing, passes Platform 2 and heads north along the Down line.
The diesel-powered multiple unit Cross Country services that run non-stop through Elsenham carry passengers between Birmingham New Street and Stansted Airport. These Class 170-hauled services are similar to the kind of diesel-powered multiple unit services operated by Central Trains in 2005, one of which struck Olivia Bazlinton and Charlotte Thompson on the crossing eight years ago.
Between 1000-1100 on Saturday morning, 7 December 2013, four such non-stopping services pass through Elsenham on the upline. Four similar services also head through Elsenham in the other direction. A freight train also passes through on the Upline.
The crossing keeper is therefore kept very busy. Three times he opens and closes the gates in a twenty-five minute period, chiefly for express non-stopping trains.
At 1056 and 45 seconds the bell sounds again. The bell rings for one minute whilst the crossing keeper closes the road crossing gates once again. Just over two minutes later, a train horn sounds. An automated voice warning can be heard at the station, stating: ‘The train now approaching Platform One does not stop here. Please stand well clear of the edge of Platform One.’
Twenty-five seconds after the announcement, Freightliner 66523, one of Freightliner’s 130-strong fleet of Class 66 locomotives, rumbles into view around the Elsenham curvature.
The hulking locomotive thunders over the road and footpath crossings at a steady speed.
A rush of air whisks up a small clutch of fallen leaves.
The train heaves it way through Elsenham station…like one of ‘an infinite number of giant buffalos charging’.
© Paul Coleman, London Intelligence, February 2014
Paul Coleman: reporting and research
House of Commons Transport Select Committee
Safety at Level Crossings, House of Commons Transport Select Committee – Eleventh Report: Safety at level crossings
International Railway Journal
Level Crossing Safety www.levelcrossingsafety.com
National Union of Rail, Maritime and Transport Workers
Office of Rail Regulation
Rail Accident Investigation Branch
Rail Safety Standards Board
Charlotte Thompson: Poetry
Reg Thompson: Dear Charlie: Letters to a Lost Daughter, John Murray, London, 2006.
Transport Salaried Staffs’ Association
Wolmar, Christian: On the Wrong Line: How Ideology and Incompetence Wrecked Britain’s Railways, Aurum, London, 2005
Letting children skate on thin ice: Level crossing safety after Elsenham
By Paul Coleman for London Intelligence, London, 2014.
© London Intelligence, February 2014. All Rights Reserved.