At 00:11 hrs on 21 July 2013, a passenger train operated by Greater Anglia carrying 35 passengers collided at 8 mph (13 km/h) with a train stabled in platform 6 at Norwich station. As a result of the collision, eight passengers with injuries were taken to hospital.
RAIB concluded that the accident occurred because during the last 20 seconds of the driver’s approach to the station, he either had a lapse in concentration or a microsleep.
RAIB identified some factors which may explain the driver’s possible lapse in concentration (ie the noise made by the passengers immediately behind his cab and the various thoughts occupying his attention at the time of the approach). RAIB also found that the driver had a previous operational history indicative that he was prone to lapses in concentration, and that this had not been identified by Greater Anglia’s competence management system.
Greater Anglia’s investigations of the previous incidents that the driver had been involved in had not raised any concerns about the driver’s ability to maintain concentration. This was because the driver manager who carried out the investigation had not been trained to consider that incidents, seemingly different in nature, could be linked by underlying behavioural issues. Opportunities to formally review the driver’s operational history were missed and this was also not identified by the internal audits conducted by Greater Anglia.
Furthermore, the driver was tired through a short-term lack of sleep, and his performance might also have been affected by the prescribed medication that he was taking. These could have been other factors leading to a lapse in concentration, or they could have led to the driver having a microsleep.
RAIB has identified two learning points and made five recommendations as a result of its investigation. The learning points relate to the importance of reporting all incidents to signallers, and the importance of providing occupational health physicians with all relevant medical information during consultation.
Four recommendations are addressed to Greater Anglia with respect to its competence management system, its accident and incident investigation procedures, its auditing processes and its fatigue management system. A further recommendation is addressed to Network Rail, with the support of Greater Anglia, to understand and mitigate the risk associated with permissive train movements at Norwich station.
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.
Published 10 December 2014