Llanboidy Crossing 19 December 2011: One crash, Four causes, 27 injured

Every day Fishguard rail passengers use the level crossing near Whitland without a second thought. But twice in the past year (and on at least one other occasion since 1994), the crossing has seen a collision with more or less serious consequences.

Llanboidy level crossing showing warning sign protruding into road

Following the latest crash in July (we published remarkable pictures on August 1st) – Fishguard Trains said “This incident, following the previous crash last December, must surely raise serious questions about the crossing design itself. We look forward to some answers – urgently.”

With the publication today of the official Rail Accident Report by RAIB, the Rail Accident Investigation Branch, we begin to receive some answers. Here we highlight key findings and recommendations in the report.

The report mainly concerns the serious accident on 19 December 2011, when the 9:10 Milford to Manchester service, travelling at 68 mph (just 2mph below the official maximum) ploughed into a hay lorry parked over the crossing. Half the 54 passengers on the service suffered injuries, 26 minor, and one serious.

The report also briefly considers the crash on 27 July 2012 when another eastbound train collided with a lorry parked stationary on the level crossing. This time there were no injuries. In the earlier December crash the lorry was prevented from clearing the crossing by the half barrier on the right hand exit side of the crossing, whereas in the July crash it was the nearside barrier coming down on the lorry flatbed that blocked its exit. It dropped between the cab and the crane on the tail of the lorry.

The immediate cause of both crashes was obviously a stationary lorry on the crossing. But the RAIB Report makes clear that no less than four factors combined to cause the December incident.

First and most plainly, the lorry driver ignored the sign reminding drivers of large or slow vehicles to call the signaller for permission to cross. The sign defines large as over 18.75m long and slow as 5mph or less – and it does so bilingually. The investigation found that despite the damage to the lorry making it impossible to measure its length accurately (the lorry was pushed 78 metres along the line before coming to rest), the combined length of lorry and trailer were calculated as 21.48m. The driver should have phoned for permission to cross the line. He did not.

Disturbingly, the report reveals that this lorry and trailer had been stopped by VOSA officers (the public agency that monitors and enforces vehicle law) on four occasions between 22 August 2010 and August 2011. On each occasion they issued a fixed penalty notice for driving a rigid vehicle and trailer over 18.75 m long. Their enforcement was not effective, as four months after their fourth penalty notice, the same vehicle came to a standstill over Llanboidy Crossing. But the report makes no comment about the effectiveness of VOSA’s enforcement.

As to the speed of the lorry as it crossed the level crossing on the morning of 19th December, the report concludes that it is likely that the driver did not see the warning “wig wag” lights illuminated when he passed them. He must have been travelling slow enough for the barriers to descend (8.5 seconds after the amber light) before he cleared the crossing. The driver was therefore “at or very close to” the speed at which a phone call to the signaller was necessary.

But despite the driver’s reported failure to observe the legal requirements, this was not the only cause leading to the crash, the report finds. Had the lorry been travelling on the left side of the road, it would not have encountered the half barrier on the opposite carriageway on the far side of the crossing. That was the half-barrier – on the exit side – that brought the lorry to a standstill across the tracks. How did that happen?

The report makes three findings: the road over the crossing is out of alignment with the rest of the road; the nearside “wig wag” traffic light signal was wrongly positioned too far out into the road; and railway contractors working on the line nearby had parked two vehicles close to the crossing partly blocking the exit.

The result of these further factors was to encourage the driver to take a line across the crossing too far out into the road. The RAIB tested the route the lorry would have had to take, to see whether it could have exited the crossing with the half barrier on the far side lowered. They found that the clearances were too small for a driver to achieve without help from someone on the ground. They repeated the test with the railway contractors vehicles parked on the far side of the crossing. The clearances were even tighter.

Most tellingly, they then repeated the tests with a shorter vehicle-trailer combination, at the maximum legal length of 18.75 metres. The clearances were no easier: “The position of the wig wag signal at the south side of the crossing forced vehicles to the right as they entered the crossing and the alignment of the road and good visibility beyond the crossing encouraged drivers to continue on the right-hand side of the road”. The picture above, from the RAIB Rail Accident Report, illustrates the problem.

The report concludes: “the combined effect of the wig wag signal being positioned too far out into the carriageway, the misalignment of the road over the crossing with the rest of the road and the position of the parked vehicles on the far side would have been to encourage a lorry driver to take a line towards the right-hand side of the road. This line was obstructed by the half barrier on the far side lowering for the passage of the train.”

While the lorry driver alone was clearly responsible for observing (or failing to observe) clear instructions on length and speed, who was responsible for these three further causal factors? For the misalignment of the road and crossing, the RAIB finds Network Rail’s risk assessments lacking. Network Rail had given Llanboidy Crossing an assessed risk of 5 on a scale from 1 (highest) to 13 (lowest). This moderate risk level did not justify substantial mitigation measures. But Network Rail’s risk assessment process does not consider “misalignment of the crossing relative to the rest of the road … if the misalignment had been considered, it is likely that the crossing would have been assessed at a higher risk which may have justified improvements” the report finds.

The report clearly finds that the position of the nearside wig wag signal “did not comply” with requirements – i.e. instead of being at least 810 mm back from the road it was 700 mm into the road – yet it makes no specific findings of responsibility for this breach. We think this is a remarkable omission. The very safety lights that are meant to protect us were themselves a hazard – and have been so since installation in 1993.

Concerning the railway contractors vehicles, left “partly obstructing the road on the exit from the crossing”, the report notes that the Rail Safety and Standards Board guidance on level crossing risk management makes no reference to “briefing railway staff on where to park when visiting crossings”.

RAIB makes six recommendations, two regarding the design of the 175 diesel units (neither of which were causal factors in the collision). The remaining four are for Network Rail and the ORR:

Firstly, and specifically for Llanboidy, Network Rail is asked to reduce the misalignment of the road at Llanboidy Crossing, and bring the signals into compliance with existing regulations.

Then they make three recommendations for the rail industry as a whole: The ORR (Office of Rail Regulator) is to issue guidance on the assessment of road misalignment at crossings and its mitigation; and further guidance to take account of the actual vehicle path of the largest vehicles permitted to cross without calling the signaller.

Network Rail is likewise to include road misalignment in its risk assessment of level crossings.

Finally Network Rail is to provide guidance to staff and contractors on where to park vehicles when working around level crossings.

This must all come as welcome news for rail travellers generally, and travellers in west Wales in particular. It was plain that a level crossing that has seen repeated collisions over the years was overdue for change. That we now seem to have.

But nagging doubts remain. The less serious crash on 27 July 2012, described but not analysed in this report, does not appear to have all the factors of the earlier incident. The lorry was approaching from the opposite direction, and was blocked not by the exit barrier on the offside but by the barrier on its own side. None of the alignment issues seen in December 2011 appear relevant in July – as far as we have been told. How would all the changes called for by the RAIB report have prevented July’s collision?

And then there is the extraordinary collision in 1994, reported by Fishguard Trains regular, Blocking Back on August 15th:

“A 158 had an even worse impact at Llanboidy Crossing on 27th April 1994. Believe it or not, a Dyfed County Council JCB driver had decided to do some digging on the crossing and had deployed the stabilisation jacks while operating the rear bucket-arm. Consequently he was entirely unable to move the JCB when the Fishguard Boat Train approached at full line speed (back then the Boat Train didn’t stop at Whitland).

The train driver applied emergency brakes and ran back into the train, shouting a warning to the passengers to brace for impact. The JCB’s front bucket hit the driver’s cab, which was utterly destroyed – the driver would have been killed had he not been quick-witted enough to bail out.

“Having been hit on the front bucket, the JCB spun in the air – the rear bucket-arm then penetrated the side of the train, injuring a woman sitting in one of the window seats. Thanks to the driver’s warning, other passengers had ducked or dived into the aisle, which undoubtedly saved lives. The rear arm of the JCB snapped off and remained impaled in the side of the train, which eventually came to a stop under the A40 road bridge. The remains of the JCB, plus driver, flew through the air for around 50 feet, taking the top half off the relay room at the crossing.”

According to the RAIB Report, Llanboidy Crossing was converted to an AHB (automatic half barrier) crossing, and then inspected and approved by Her Majesty’s Railway Inspectorate in May 1993. (The RAIB Report points out that the warning lights were non-compliant even in 1993 when inspected by the HMRI. In other words, the safety inspectorate approved hazardous lights.) Eleven months later came the collision with the JCB. Once again it is not clear that any of the factors and recommendations in this new report could have any bearing on the 1994 incident.

Rail is our safest mode of transport, but time and again, its fine safety record is undermined by coming into direct contact with road transport. We put up with the risk because the cost of separating road and rail at countless level crossings would challenge any transport budget. But that is only acceptable with rigorous risk assessment and management. The catalogue of shortcomings in level crossing management exposed by this report into just one collision will, we assume, now be addressed. That’s good.

But what of the shortcomings that may have caused the other collisions at Llanboidy? Until they are known and addressed, shouldn’t Llanboidy Crossing be closed to all vehicles?

[all quotations taken from RAIB Rail Accident Report. Collision between a train and a lorry and trailer on Llanboidy automatic half barrier level crossing 19 December 2011. Crown Copyright. Department of Transport, September 2012, accessed at http://www.raib.gov.uk/cms_resources.cfm?file=/120927_R202012_Llanboidy.pdf ]

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