Report 04/2023: Near miss at Farnborough North footpath level crossing
RAIB has today released its report into a near miss at Farnborough North footpath level crossing, 19 May 2022.
Farnborough North footpath level crossing, shown to the left of the image and adjacent to a user worked crossing which was not involved in the incident.
Summary
At 08:20 hrs on Thursday 19 May 2022, 144 people were waiting on the east side of the railway to use the footpath level crossing at Farnborough North station. Pedestrian gates on each side of the crossing were locked until a train had departed from the station. The crossing users had arrived on this train and were mostly young people. They were regular users of the station and normally had to wait before crossing the railway to continue their journey to school or college. There is currently no footbridge or subway at this station.
After the train departed, miniature stop lights at the crossing changed from red to green and an audible warning stopped, indicating that it was safe to cross the railway. A crossing attendant, located in a cabin next to the crossing on the east side of the railway, responded by turning a switch to remotely unlock the pedestrian gates at both ends of the crossing. The person at the front of the queue opened the gate and the group started to cross the railway. Each person held the gate open for the person following them.
When around half the group had crossed, the miniature stop lights changed from green to red and the audible warning started, indicating that another train was approaching. The crossing attendant turned the switch to lock the gates, but crossing users continued to pass through the gate until the crossing attendant left their cabin and directly intervened to close it. The driver of a train approaching from around a bend in the track saw people on the crossing ahead and applied the train’s emergency brake and sounded the horn. The crossing was clear before the train passed over it.
Network Rail staff undertake regular inspections and risk assessments of level crossings on the national rail network. Farnborough North footpath crossing is considered a high-risk location because of the limited sighting of trains, the number of daily users and a history of safety incidents. In 2013, Network Rail installed additional ‘back-to-back’ miniature warning lights to help with user decision making. Network Rail subsequently provided a crossing attendant and lockable gates to manage the risk until it could permanently close the crossing and replace it with a footbridge.
RAIB’s investigation found, however, that Network Rail had not developed a plan or training which would enable the crossing attendant to effectively manage the residual risks that remained at the crossing following the installation of lockable gates. RAIB also found that the project to construct an accessible footbridge had not obtained planning approval over a prolonged period because of land ownership issues and the need to design a compliant structure which was suitable for the constrained site.
Recommendations
RAIB has made two recommendations to Network Rail regarding improvements in the risk assessment process for footpath level crossings where there is a history of safety incidents occurring, and formalising competency requirements for temporary and interim crossing attendants. RAIB has also identified one learning point for railway organisations which are reminded that complex projects, or those requiring engagement with external stakeholders over an extended period, require managerial continuity.
Andrew Hall, Chief Inspector of Rail Accidents said:
This incident was particularly serious because it involved large numbers of school and college students crossing the railway on a footpath crossing, ahead of a train travelling at speed. A serious accident was probably avoided due to the quick thinking of the crossing attendant who, on realising the danger, ran to intervene directly by closing a crossing gate that the students were holding open for each other.
Behind the incident was an issue of the type RAIB has seen before. Historically the railway knew of the risks at this crossing and ongoing efforts were being made to replace it with a footbridge. This was proving time consuming and difficult, as is sometimes the case when planning decisions are involved. In the meantime, additional warning lights were installed, and a crossing attendant was provided to remotely control electromagnetic locks on the gates, thereby reducing risk. However, a known residual risk was that the crossing’s users might not respond correctly when the audible alarm and warning lights were activated by an approaching train. In this case people held open the gates for each other as the train approached, meaning the attempted application of the gate locks by the attendant had no effect.
If a known level of residual risk is allowed to persist for a long time, the chances of it manifesting itself as an accident or serious incident will inevitably rise. This is what happened at Farnborough North and is why the incident holds a powerful lesson.
Notes to editors
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The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.
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RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.
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