RAIB report after train crash at Nordan in Herefordshire

The Rail Accident Investigation Branch investigation was launched after a train crashed into a trailer being pulled by a tractor crossing the lines at Nordan in Herefordshire on May 22 last year.

Now, the RAIB investigation has found, the accident happened because the signaller gave permission to the tractor’s driver to use the crossing, despite the proximity of the approaching train.

"The signaller had forgotten about the presence of the train when they gave permission and did not check signal box equipment which was indicating the presence of the train beforehand, as they had been trained to," the report said.

"The signaller’s actions may have been affected by an interruption to their established routine for giving users permission to use the crossing, an increase in their workload, distraction and the effects of fatigue."

The train was travelling between Ludlow and Leominster at around 80 mph (129 km/h) at the time of the crash, the report said.

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Six passengers and one member of staff received minor injuries. The train did not derail, but significant damage was caused to both the train and to the agricultural trailer.

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The report said Nordan Farm level crossing is a "passive user worked crossing", meaning it has no engineered safeguards to warn or protect a crossing user of an approaching train and safe operation is solely reliant on the signaller’s decision as to whether it is safe to cross or not.

Investigators found that Network Rail’s level crossing risk assessment process did not effectively recognise nor control the higher risk present at some crossings during intensive seasonal use, which it said was an underlying factor.

The investigation also found that Network Rail did not have a coherent process for deciding whether a vehicle using a user worked crossing should be considered as large, low or slow moving.

The RAIB has made two recommendations, both addressed to Network Rail. The first seeks to improve the effectiveness of risk management processes at crossings that see a high variance of use across the year. The second asks Network Rail to consider the actions it took in response to a previous RAIB recommendation and is aimed at assisting signallers and crossing users in deciding whether a vehicle should be treated as large, low or slow moving.

The RAIB also identified four learning points. The first reminds staff to comply with their company’s mobile phone policies. The second reminds staff to assess their level of fatigue and inform their company as needed. The third highlights the importance of signallers using available instruments and indicators when considering level crossing requests. The fourth reminds signallers to follow the correct process for applying signal protection.