Report 03/2022: Near miss at Coltishall Lane User Worked Level Crossing
RAIB has today released its report into a near miss at Coltishall Lane User Worked Level Crossing, Norfolk, 21 January 2021.
Summary
At 17:21 hrs on 21 January 2021, a passenger train narrowly avoided a collision with two cars at Coltishall Lane user worked level crossing, near Hoveton, Norfolk. Road traffic over the crossing was higher than usual as a result of drivers seeking a diversionary route for their journeys, following an earlier road traffic accident on a nearby main road.
The safe use of the crossing relied solely on telephones to warn users in road vehicles of approaching trains, and the near miss occurred because the car drivers did not telephone the signaller before using the crossing. The investigation found that this may have been because the car drivers were unfamiliar with the crossing, because the signs at the crossing were ineffective in prompting users on how to cross safely, and because the level crossing gates had already been opened. It is also possible that factors such as the increased level of road traffic may have affected the behaviour of road users and their decision-making.
The investigation also found that Network Rail and its predecessors had not taken measures to close or upgrade this crossing, despite being aware of the risks it posed. This was possibly because Network Rail’s processes for assessing and controlling risk at the crossing did not take account of some of the factors present, leading to an incomplete understanding of the risks involved in its operation. Additionally, the status of user worked crossings on public roads was not acknowledged within relevant statutory provisions and industry guidance, and this may have affected how safety at these crossings was managed by infrastructure managers. The Office of Rail and Road had previously taken regulatory action, but this had not resulted in action by Network Rail to address the risk at this crossing by the time the near miss occurred.
Recommendations
RAIB’s report makes three recommendations. The first is that Network Rail should assess, and if necessary reduce, the risks of incidents and accidents at vehicular user worked crossings which may see significant use by unfamiliar users, consistent with current industry best practice. The second is that Network Rail, in consultation with the Office of Rail and Road and the Department for Transport, should improve signage at user worked crossings which may share features identified in this investigation. The third is that the Department for Transport, in consultation with the Office of Rail and Road and Network Rail, should evaluate the extent to which recent guidance on the drafting and making of level crossing orders will better enable the implementation of improved safety measures at level crossings.
There is one learning point that reminds those responsible for the management of safety of user worked crossings to adhere to the principles of level crossing risk assessment published by ORR in June 2021.
Response to recommendations:
- RAIB will periodically update the status of recommendations as reported to us by the relevant safety authority or public body
- RAIB may add comment, particularly if we have concerns regarding these responses.