The Rail Accident Investigation Branch (RAIB) has today released its report into the fatal accident which occurred at Mexico footpath crossing, near Penzance, 3 October 2011.
A full copy of the report is available here:
Summary
At around 15:50 hrs on Monday 3 October 2011, a pedestrian, Mrs Nicholls, was struck and fatally injured by a train on Mexico footpath crossing, near Penzance in Cornwall. The footpath crossing was not equipped with warning lights or alarms and pedestrians were required to look and listen for approaching trains. The pedestrian’s ability to see approaching trains was restricted by line curvature to a maximum of about 190 metres and a ‘whistle board’ was situated 348 metres (around 15 seconds running time) from the crossing to provide additional warning. Train drivers were required to sound the train’s warning horn when passing this board and the driver of the train involved in the accident had done so. On approaching the crossing round the curve, the train driver had observed a person standing to the side of the line and had sounded the warning horn again before the train reached the crossing. However, the pedestrian then attempted to cross and was struck.
In the few seconds immediately before the accident when the train was in view, the pedestrian either misjudged the speed of the approaching train or misjudged her position in relation to the approaching train, having probably seen the train too late to have time to make a reasoned judgement about whether she should cross.
It is not known why the pedestrian was apparently unaware of the train horn that was sounded around 15-16 seconds before the train reached the crossing. Either the horn was inaudible to the pedestrian because of the train’s distance from the crossing when it was sounded or it was heard by the pedestrian, but not associated with a train.
The RAIB also observed during its investigation that:
- Network Rail is not consistent in the approach that it takes in measuring sighting distances at level crossings;
- the optimum point at which a pedestrian should make a decision to cross (the ‘decision point’) was not marked at Mexico footpath crossing - the industry has made little progress to date in researching the issue of marking decision points despite previous RAIB recommendations in this area;
- the positioning of whistle boards at level crossings across the main line railway network is not optimised to local conditions; and
- train horn testing is not mandated following relevant accidents or incidents.
As a consequence of this accident, the RAIB has made five recommendations:
- Three recommendations have been made to Network Rail regarding:
- changes at Mexico footpath crossing that will improve pedestrians’ warning of approaching trains;
- expediting the marking of decision points at level crossings and achieving consistency in the way that sighting distances are measured;
- replacing the warning provided by train horns at whistle boards with audible and/or visual warnings at crossings, and, where this is not reasonably practicable, optimising the positioning of whistle boards to local conditions.
- One recommendation has been made to RSSB regarding enhancing industry’s existing processes for gathering incident data to enable a full evaluation of risk at level crossings to be made and for reviewing the effect of the change that was made in April 2007 to sounding a single tone only of the train horn at whistle boards.
- One recommendation has been made to First Great Western to propose a change to Railway Group Standards to mandate the objective testing of train horns after incidents and accidents where the sounding of the train horn was either required by the rule book or employed by the driver during the event.