At 08:22 hrs on 28 March 2015, a freight train running from Acton to Westbury, operated by DB Schenker Rail (UK), passed a signal at danger at Reading Westbury Line Junction, to the west of Reading station. A similar incident occurred at 06:11 hrs on 3 November 2015 when another freight train forming the same service from Acton to Westbury, and operated by the same company, passed a signal at danger at Ruscombe Junction, about seven miles east of Reading. RAIB began an investigation into both of these incidents following the latter event at Ruscombe Junction, owing to the similarities between them.
Both incidents occurred because the train drivers involved were too fatigued to properly control their trains; both drivers stated that they momentarily fell asleep on the approach to the signals concerned. They were suffering from fatigue because they had not obtained sufficient sleep, which in part was due to the rest facilities at Acton not being fit for purpose, and because the drivers were nearing the end of a long night shift. Neither driver reported as unfit for duty, which was also causal to the incidents. The investigation identified underlying factors associated with supervision and management at the drivers’ home depot in Westbury, and with the general approach to the management of fatigue within the company.
As a result of this investigation, RAIB has made three recommendations covering shift planning at Westbury depot, fatigue management within the freight sector and identification of fatigue risk through data analysis.
RAIB has also identified two learning points concerning the importance of preparing for duty and reporting fatigue, and the role of napping (and facilities for such) within a fatigue risk management system.
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 29 September 2016