Lack of safety compliance a factor in Loughborough SPAD

The Rail Accident Investigation Branch says that while the root cause of a Signal Passed at Danger (SPAD) at Loughborough was a train of two locomotives and an empty unbraked Class 710 electric multiple unit travelling too fast for its braking capability, an underlying factor was that the train operator’s management assurance processes did not detect a lack of compliance with its own safety management system.

The train, operated by Rail Operations Group, was the 0957 Old Dalby-Worksop Down Yard. 57305 was at the front of the train and 57310 at the rear.

At around 1057 on March 26 2020, it passed signal LR507 at danger on the Down Slow line, around 0.75 miles south of Loughborough station. The train was braking as it passed the signal at around 20mph and stopped 200 metres beyond it. This exceeded the safety overlap of the signal but was 600 metres short of the point at which conflict with other train movements might have occurred.

The driver stated that he believed the maximum permitted speed of the train to be 75mph, based on information provided to him on a train planning document. However, the maximum permitted speed was 60mph.

RAIB found a lack of compliance in areas of ROG’s safety management system that resulted in the driver and shunter being inadequately prepared for the movement of the train.

It also observed that the driver did not conduct an adequate running brake test at the beginning of the journey, and that Rail Operations Group did not adequately manage the retrieval of evidence from the on-train data recorders (OTDR) in the locomotives.

RAIB asked ROG to download the OTDR data from the locomotives. Owing to nonavailability of individuals and equipment capable of performing the download, this did not take place until four days after the incident.

Although most modern OTDR equipment can store at least eight days’ worth of data (in line with current industry standards), when it was downloaded from the Class 57s involved, it was discovered they had stored just over eight hours’ worth of data. This meant that the data associated with the incident had been lost. The equipment on the locomotives complied with a previous standard that specified a minimum of eight hours’ storage.

RAIB recommends that ROG reviews its management assurance processes relating to operational safety and takes steps to ensure effective monitoring, auditing and management review of its safety arrangements. These should include the competence management of operational staff, traffic acceptance and general operating instructions.

A learning point highlighted the importance of being aware of and adhering to maximum permissible speeds for the type of train being operated and for the section of line on which it is being driven.