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 ]

9 Comments

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

  1. Irishman

    In my view a measure which seems quite prudent and readily implementable is that a reduced line speed limit (e.g. 40m.p.h.) be applied in the crossing’s vicinity.

    The downside in terms of a very slight increase in journey time seems quite justified.

    • Rhydgaled

      Why should the railway be slowed down (I’m supprised the linespeed is only 70mph, not 75 since even Pacer units can go that fast) when it is the road that causes the saftey issues? We need to encourage a more pro-rail attitude over the pro-road one that has been, and in many areas still is, prevalant. Swansea Jack has said “With the number of incidents at Llanboidy Crossing over the years it’s surely time for NR to convert it to a foot crossing.” That suggestion sounds more like the correct attitude.

      Reducing the linespeed to around 40mph as you suggest would probably be a good idea provided it is only as a temporary measure. This reduction in train speed should only be until NR decide to close it to road vehicles or carry out work to greatly improve the saftey of the crossing. In fact, when the July collision occoured maybe a temporary limit to linespeed should have been applied right away. Appologies if this is what you meant, but you sounded as if you were suggesting a permenant reduction in linespeed.

      I would expect the RAIB will produce a report on July’s collision at some point and hopefully this will find more factors that can be fixed.

  2. Swansea Jack

    The direct cause was that the lorry driver stopped on the crossing when the sirens started and the barriers came down. Given a choice of trashing the barriers by continuing out of the way, or remaining on the crossing which would have caused a collision with a train likely to cause serious injuries he decided on the latter. My question is who the hell allows HGV drivers with this level of stupidity to drive anything above a SCALECTRIX car?

    The inability of said driver to remember the length of said truck and trailer combination even after fixed penalty notices is also worrying – he had no excuse in not phoning the signalbox as the regulations required. Finally how many fixed penalty notices about the illegality of said vehicle combinations is needed before either a) the authorities deal with the situation properly rather than just issuing more fixed penalty notices, or b) the owner(s) of said vehicle actually do something about it themselves.

    I wonder whether this vehicle still travels on the roads around Whitland in the same illegal way, and wonder what charges will be brought on the driver, and company involved, for endangering passengers and others upon the railway?

    I appreciate that there were contributing issues here, which should have caused the driver to be more considerate over using the crossing, and trust that NR will eliminate the issues raised about such wide / long vehicles being able to exit the crossing Northbound even as the barrier is dropping on that side as a priority, but lets remember it was the illegal road vehicle who’s driver didn’t follow instructions pertaining to the length of his vehicle that caused this accident.

    It is well accepted that the biggest risk to rail transport safety these days is at level crossings when the far lower safety levels applicable to road transport interface with trains. Consider the issues at Llanboidy along with those near Kidwelly in the recent past, while 2 of the last 3 major rail accidents in the UK at Ufton Nervet and Great Heck were both caused by road vehicles.

    Remember however that rail is a far safer mode of transport than road, only 1 rail passenger having died since 2005 in the UK.

    • Spad

      Can’t let you get away with simply blaming a bad lorry driver for this crash. As our story says (and as RAIB makes clear) this was a collision that had not one but FOUR causes. The other three causes reflect very poorly indeed on the railway and safety authorities.

      You acknowledge, Swansea Jack, that “the biggest risk to rail transport safety these days is at level crossings when the far lower safety levels applicable to road transport interface with trains.” So railway authorities have no excuse to fail to plan for the expected bad behaviour of road users. How did they perform at Llanboidy?

      1 Network Rail installed warning lights in breach of regulations. They have been causing a hazard for nearly two decades.

      2 The railway inspectorate (HMRI) approved these dangerous warning lights in 1993. For nearly two decades, those lights have been forcing lorries to pull over to the right, into the path of the offside half barrier. RAIB records this as a cause of the collision.

      3 The danger was not only to lorries longer than the legal limit, or indeed just to lorries that failed to stop and call the signalman. RAIB tests revealed that even lorries within the 18.75 meter limit were forced to pull over by the dangerous lights.

      4 VOSA was plainly well aware of this lorry and driver – they issued four fixed penalties between 2010 and 2011. But each time they left the driver to keep going as before, putting us all at risk. They failed to intervene, or to escalate the problem to an authority who would intervene.

      In other words, two safety authorities, both rail and road, failed the public, failed rail users, failed in their duty to keep us safe. There will always be delinquent drivers. We do not also need incompetent safety authorities.

  3. Irishman

    No problem Rhydgaled, I fully agree that the railway shouldn’t have to be slowed down because of road issues and had only suggested the line speed reduction as a temporary measure (I should have said temporary in my post).

  4. Swansea Jack

    Fair comment SPAD. I did mention the contributing factors, and that I trusted NR would eliminate the issues which prevented longer and wider vehicles from being able to safely exit the crossing in a Northbound direction if the barriers started to drop while the vehicle was negotiating the crossing. I accept that I made more emphasis on the driver’s part, probably because from experience I would expect the RAIB recommendations to be followed up by the rail industry, but have less confidence in the road industry doing the same.

    The issue of slow, long road vehicles on crossings has been an issue for many years, Hixon comes to mind from the 1960s.

    Yes, it does seem rather strange that the original inspection by the Railway Inspectorate, of the crossing passed something which failed to meet requirements, and the fact that we have had 2 incidents in the last year together with the 1980s incident will hopefully lead to swift action by NR and the highway people to amend the road layout, and in particular the signage approaching the crossing. How we ensure drivers of overly long, wide or slow road vehicles to treat railway crossings with respect is a trickier issue unfortunately. It is to be hoped that the ongoing programme to replace as many level crossings with bridges will continue as swiftly as finances allows to reduce the possibility of further accidents.

    I have friends who lost colleagues at both Ufton Nervet and Great Heck by the way, in tragic circumstances that should have been avoided.

  5. Dave H

    Tom McCartney the recently retired Traffic Commissioner railed in his final annual report about the lack of a formal process to feed the detail of FPN and other infractions from VOSA and the Police to the Traffic Commissioners, and the resources to process this. The tally of offences committed by Operators and Drivers, that onloy comes to light AFTER that big crash or fatal injury to a less protected road user.

    Examples include Denis Putz who was still holding a vocational licence with a string of over 20 driving convictions (killed cyclist when driving 32T tipper drunk from previous night and using phone) or Joao Lopes, killing a cyclist and then a pedestrian, with a string of minor crashes between over a 2 year period, because he drove with defective eyesight.

    Crossing alignment and surface condition is also an issue which is not really recorded effectively. I note this as a 2 wheeled road user, where surface defects have a far greater effect than on a motor car or truck. Worse still is the under-reporting of minor injury incidents, where only an injured person is left lying across the live railway (considered less serious than a car), near misses have never appeared on signallers log or as the RIDDOR report (level crossings are covered by HSAW Act as highlighted by the prosecution for Elsenham – Section 3 Duty of care to non-employees).

  6. Swansea Jack

    The driver of the hay lorry has pleaded guilty to endangering the lives of passengers on the railway at Swansea Crown Court. Sentencing has been adjourned until 26th October. Report here http://www.bbc.co.uk/news/uk-wales-south-west-wales-19786487 .

  7. Local user

    I offered to privately show NR inspectors the users view but to no avail. It is not mentioned in safety report. Furthermore the trains do not whistle when approaching given there is only 15seconds between first light flashing and train passing it’s not much time. The wobbly ness has been improved recently but poor visibility not. Who would be daft enough to entirely trust a flashing light and not keep one eye open for the very large long moving fast lumps of metal coming round the blind bends .. This self preservation action does contribute to slow crossing.

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