Investigation of a Near-Miss: Fatigued Driver or Chiltern Railways Processes?
The Rail Accident Investigation Branch (RAIB) launched an investigation after a near-miss with a Chiltern Railways train.
At around 9:43 pm on Sunday, June 21, 2020, a near-miss occurred between two passenger trains — one a Chiltern Railways train — at London Underground’s Chalfont & Latimer station on the Metropolitan line. A few minutes earlier a southbound Chiltern Railways train had passed a signal displaying a red (stop) aspect (known as a signal passed at danger or a ‘SPAD’). This resulted in the train being automatically stopped by a safety system, known as a tripcock, which had applied the train’s emergency brake. Without seeking the authority required from the service operator (signaler), the driver reset the tripcock before continuing towards Chalfont & Latimer station, where the train was routed towards the northbound platform, which was occupied by a London Underground train.
The Chiltern Railways train stopped about 23 meters before reaching the other train, which was stationary. There were no reported injuries, but there was minor damage to signaling equipment and a set of points.
The Chalfont & Latimer station near-miss: The probable cause of the SPAD (signal is passed at danger) was that the driver of the Chiltern Railways train was fatigued.
The driver stated that he decided to proceed without authority because he did not recall passing the stop signal and believed the tripcock safety system activation had been spurious. This decision may also have been affected by fatigue.
RAIB found that, in the Chalfont & Latimer station near-miss, the processes of Chiltern Railways for training and testing a driver’s knowledge of what to do following a tripcock activation were not effective.
A probable underlying factor was that Chiltern Railways’ driver management processes did not effectively manage safety-related risk associated with the driver involved in the incident. It is possible that this was a consequence of a high turnover of driver managers, insufficient driver managers in post and their high workload. Although not causes of the incident, RAIB also found shortcomings in other aspects of these driver management processes, and in risk management at the interface between Chiltern Railways and London Underground (at Chalfont & Latimer station).
RAIB recommendations for Chiltern Railways
RAIB has made three recommendations and identified one learning point.
- The first recommendation is that Chiltern Railways improves its driver management processes.
- The second recommendation is that Chiltern Railways and London Underground Ltd jointly establish an effective process for the management of safety at the interfaces between their respective operations.
- The third recommendation is that Chiltern Railways, assisted by London Underground, reviews the risk associated with resetting train protection equipment applicable to Chiltern Railways’ trains on London Underground infrastructure. The learning point concerns the importance of considering sleep disorders during routine medical examinations of safety critical workers.
Source: RAIB Rail Accident Report, “Signal passed at danger and subsequent near-miss, Chalfont & Latimer station, 21 June 2020,” July 2021.
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