Failure to lock points caused serious irregularity at Cardiff, says RAIB

An Arriva Trains Wales CardiffTreherbert train almost traversed incorrectly-set out-of-use points near Cardiff Central on December 29 2016, according to a Rail Accident Investigation Branch (RAIB) report.

It found that points taken out of use during Cardiff Area Signalling Renewal (CASR) scheme works from December 24 2016 to January 3 2017 were not secured in their correct position for a new track layout in readiness for removal at a later date. The driver of the 0836 Cardiff Central-Treherbert train noticed that points 817A were not in the correct position, stopping short of them and alerting signallers at 0837. Had he not noticed the position of the points and stopped, the train would have been diverted onto a bidirectional line open to traffic and over which another train passed about three minutes after the train involved in the incident came to a standstill. The new signalling system uses axle counters for train detection, which the RAIB points out would not have immediately identified that the train was in the wrong place.

The points had been left in an unsafe position because they had not been identified as requiring securing by the team during the signalling renewal works. The RAIB’s investigation also found that nobody had checked that all the points that needed to be secured during the CASR scheme had been. Route-proving trains had been cancelled by agreement with train operators due to an engineering possession overrunning.

RAIB’s investigation also found that a ‘work group culture’ had developed between longstanding members of the project team that led to ‘insular thinking’ about methods of work and operational risk. Team members relied on verbal communications and assurances.

The RAIB has recommended that Network Rail (NR) should review its project assurance process as applied to the CASR scheme, and identify the deficiencies which resulted in the management shortcomings outlined in the report. RAIB has also recommended that NR should review the document management system used for the CASR project and ensure that any identified areas for improvement are incorporated into systems currently and planned to be in use by other projects.

Its final recommendation is that NR, in conjunction with contractors, should review how it implements its standards and processes relating to the management of fatigue risk. This follows a finding that the project team (excluding Atkins, which used a different system) had signed up to a fatigue management agreement which was not effectively implemented.