Signals to Danger

Season One – Episode 23 – 2010

Podcast Introduction

Hello again, and welcome back once again to Episode 23 of Signals to Danger

As I do every episode, I’ll open by thanking you for your downloads, shares and likes and your interaction on social media. And I’ll remind you that should you want to join those conversations you’ll find the podcast at @signalstodanger and me at @danielfoxrail on twitter, and the podcast is on Facebook and Instagram as well.

As ever, I’ll remind you about our website, signalstodanger.com. On there you can find show notes, transcripts, the shop and more. 

While you’re on there there is also a page on how you can support the podcast if you wanted to. There’s a link there for the Patreon, and I would love to take the opportunity to thank VK4501 for signing up. 

With that brief intro out of the way the episode!

Prelude

For some people waiting at a level crossing is a part of everyday life. The alarm sounds, the lights flash and the barriers come down. And then you wait. But when the barriers lift up again and the lights are out, well then it’s time to drive off again. But what if pulling forward was the most dangerous desicion you would ever make.

The year is 2010, and the place, Moreton-on-Lugg

Episode Introduction

 This is Signals to Danger, A podcast where we look at major rail disasters which have occurred in the UK, explain what happened, how the investigation was carried out, and how each of these accidents shaped the industry going forwards.

I’m Dan, I work within the rail industry in my day to day life but today I’ll be the one taking you through this podcast.

We start every episode by briefly revisiting the events which were taking place at the time, and this episode is no different, so let’s have a look at 2010 

January changed the face of going on holiday, when full body scanners were introduced at airports due to previous attempts to down aircraft. 

March brought with it the first British airways strikes, and the charging of Levi Bellfield with the murder of surrey teenager Milly Dowler.

15th April saw A cloud of volcanic ash from the eruption of Eyjafjallajökull in Iceland caused the closure of airspace over the United Kingdom and northern and western Europe. The 6 day shutdown was the longest air traffic shutdown since the second world war and led to a total loss for the airline industry of 1 billion pounds.

May brought us a general election, and a hung parliament. THus rose the question, would you rather be lib-labbed. Or con-demmed… As history would have it, the liberals and the conservatives formed a coaltion, bringing us david cameron and his deputy prime minister, Nick Clegg.

June brings an incredibly rare occasion to our shores, as  taxi driver Derrick Bird, went on a killing spree in Cumbria, taking the lives of 12 and then his own. And then a month later Raul Moat adds his name to those who have taken lives with firearms in this country. He kills one, wounds another and blinds a policeman before a week long manhunt sees him take his own life too.

At the end of the year the Ark ROyal, britains flagship returned to our shores to be scrapped. A veteran of worldwide conflict, her time was no doubt throughtougjly appreciated by many.

And that was a snapshot of 2010, but to tell todays story, we only need to head around 2 weeks into the year. January 16th.

<Musical interlude>

An introduction to the Welsh Marches line

As we go through this podcast we keep finding ourselves coming back to one of a few very busy main lines. THis isn’t without reason, as the main lines tend to have the higher speeds and the higher volume of traffic, so in turn they tend to feature more prominently in accident reports!

Sometimes however, our tales will bring us away from the main arterial routes, and we’ll find ourselves on the more parochial routes of the network. This time round for example, we’re not hanging out on the east coast main line, the great western or the great eastern. This time, we’re headed for the Welsh Marches Line.

The Welsh Marches is a line which connects the south of wales to the north west of england, via an area of land known as the welsh Marshes. Note one is marshes, and one is marches, and I’m not really sure why, perhaps somebody could enlighten me!

In any case, the line travels between Shrewsbury and Newport, and along the way it travels through some beautiful english and welsh countryside, over bridges and rivers, and through some delightful towns and villages. 

Some of these towns and villages are large and well known such as Hereford, Abergavenny, pontypool whereas others are small and known only to those with a reason to know them. 

Pontrilas, Dinmore, Ludlow. 

Moreton-on-lugg.

The village of Moreton-on-lugg is home to 920 people, a village inn and a church. Like so many other villages up and down the country it was a picturesque home to those who lived there, and relatively inconsequential to those who didn’t now of it’s existence. 

3 miles to the North of Hereford, Moreton was also the former site of a railway station on the Marches line, although this was closed in 1958. All that remained now of the infrastructure was the line itself, a signal box, and a level crossing which, on the 16th January 2010, would help to catapult the name of the village out of obscurity and into the national news.

<musical swell>

The Train and it’s journey

Last time we were together we started by discussing the rail network in and out of Manchester, and although Moreton is a cool hundred miles away, we find ourselves discussing it once again, albeit briefly. 

On the peaceful saturday morning which was the 16th January 2010 a train stood in the platforms of Manchester Piccadilly station. A class 175 diesel multiple unit operated by arriva trains wales. Built a decade earlier by Alstom, the 175 comprised of around 200 seats spread out between 3 carriages. Slung underneath them were 3 450 brake horsepower cummins engines which would bring the carriages up to their top speed of 100 miles an hour.

The train was one of Arriva Trains fleet providing essential transport links to the people of Wales and the Borders, and on the morning of the 16th 175103 was ready to carry out that role in full. 

At 0830, the driver of the train took his signal and started to take his train out of Manchester Piccadilly Station under the headcode of 1V75, headed out on a journey which would become far more dramatic than any of it’s previous ones. 

1V75 was a journey between Manchester and Milford Haven, on the pembrokeshire coast of South Wales. The first leg of the journey took them as far as Crewe, where the driver alighted. He was replaced at this point by another driver, one based out of Cardiff, it was he whole would take the train forward on the second half of the journey. 

1V75 proceeded south, continuing along it’s journey. And as far as rail journeys go this was not a short one. A cursory glance today at this line of route brings up a length of 6 hours and 26 minutes with 24 intermediate stations. The full journey is only 170 miles, but that is as the crow flies. With this train travelling via Hereford, Newport, Cardiff and Swansea, to name a few, the route was a little longer than that, closer to 250. 

At 20 past 10, a little under 2 hours since the Arriva trains service had departed Manchester, it arrived in the Herefordshire market town of Leominster. 

1 minute later the driver departed the station, with 32 passengers on board, as well as two other members of traincrew. With a gentle application of power, 1V75 continued on down the welsh marches line, and into the area of Moreton on Lugg.

<Musical Interlude>

The Accident & Aftermath

A little ways down the line was the signal box at Moreton-on-lugg. The box was responsible for both the section of line between Leominister and Hereford, as well as a level crossing located directly outside the box. With absolute block being the name of the game here, the signaller at Moreton was responsible for accepting trains from adjacent boxes when safe, and offering them to the next box to continue their journey. 

On the morning of the 16th, the man holding this responsibility was Adrian Maund. Employed by Network Rail as a signaller, he had 19 years experience on the railway, all of them gained at Moreton-on-lugg signal box. To say that he was knowledgeable about the workings here might be an understanding.

Leominster signal box offered 1V75 to Maund just after 20 past 10, and Maund accepted the train. At 10:22 the train passed the section signal at Leominster, LE27. V75 was now Maunds responsibility.  Continuing south the train passed through a tunnel at Dinmore, and was now approaching Moreton. Around this point Maund also accepted another train from the South, 1W85. 

1V75 passed over Ox Pasture Farm No.1 user-worked crossing at 10:27, off to the side was a farmer waiting to cross the line with some sheep, not a rare sight in this neck of the woods and nothing to cause any concern, these blokes were well used to using user worked crossings safely.

Around a minute later however something very unusual happened. At 10:28 V75 was approaching signal ML42, the signal aspect changed. The arm of the signal snapped back to horizontal. Danger. 

The driver of the train reacted immediately, he was less than 10 seconds away from the signal when it reverted in front of him, he applied the trains full service brake to bring it to a stand. This means the brakes were as fully on as they could be, without hitting the emergency plunger. 

Seconds later something even more terrifying was visible from the cab of the train. As 1V75 bore down on the signal box at Moreton on Lugg, the barriers of the adjacent crossing started to rise. The forward facing CCTV of the train captured this at 10 28 and 50 seconds. 3 seconds later the driver saw the first vehicles starting to move out into the crossing. 

This all happened really quickly by this point, 4 seconds later the barriers were vertical, and the cars were beyond the traffic lights on the road. 

At some point in this terrifying few seconds the driver of 1V75 applied the full emergency brakes and sounded the horn, but at this distance and speed it made no difference. Despite the full force of the trains braking it was still travelling at 58 miles an hour when it collided with two cars which had begun to cross the line. 

The first car, which had been waiting on the west side of the line before it started to cross, was a Vauxhall astra. The right hand side of the train collided with its front end heavily 

damaged, it’s bonnet ripped clear off to the side and the whole car spun around pointing down the line. The glancing nature of this blow meant that the occupants suffered only minor injuries.

The same could not be said however for the other. Waiting on the opposite side of the line was a Volkswagon Touareg. They had been marginally quicker off the line when the barriers raised, and this meant that at the time 1V75 arrived at the crossing it didn’t collide with the front end of the car, but rather the offside of the car. THe VW was pushed off the crossing and spun around, heavy damage being caused to the car, as you would expect from a 58 mile an hour collision. 

Immediately following the accident Adrian Maund contacted the emergency services, he called for all three to attend immediately. This was backed up by a simultaneous emergency call from the driver of 1v75 over the national rail network. The precursor to GSM-R we have nowadays.

At 10:33 hrs the signaller informed the Network Rail control office in Cardiff. He confirmed that he had called the emergency services, and that all lines were blocked. Around the same time, the front CCTV on train 1V75 showed train 1W85 arriving on the up main, and stopping short of the accident site. At least a second collision had been successfully avoided. 

Road based Ambulance crews were reported to be on site by 10:38, with the air ambulance arriving at 10:50. Before they arrived however others had attempted to provide first aid to the occupants of the Touareg, including the far less severely injured occupants of the Astra. 

The Touareg contained Mark and Jane Harding. A normal couple headed out on that most normal of Saturday tasks, a shopping trip. Their day was turned upside down at 10:28 when the front end of a passenger train violently collided with them at Moreton on Lugg. 

Both were taken to hospital, Mark’s injuries were significant, and ended up having a three day stay. Jane’s injuries however were so severe she was airlifted to the hospital in Hereford. While Mark survived to tell the tales of the day, his wife tragically succumbed to her injuries later in the day. 

This incident which took place unexpectedly and violently in the Herefordshire countryside brought with it a death toll of one, but with level crossings like this found all over the country, one was, and always will be, far too many.

 <Musical Interlude sad/dramatic – Reprise?>

Introduction to the Investigation

The investigation into the disaster at Moreton started almost immediately. Investigators from the RAIB, the Rail Accident Investigation Branch, descended on the scene. 

Every day, thousand of trains cross over hundreds of level crossings, up and down the country. At speeds ranging from 5 miles an hour up to 125 miles an hour. While the danger to cars and their occupants is clear when they meet a train, we can’t ignore the risk to trains themselves as well. We learnt in episode one what drastic effects can be found when cars and trains collide. Great Heck was the scene of a horrific train crash, triggered by a car ending up on the railway line. Lockington, 35 years ago, almost to the day when this episode airs, was the result of trains and a car trying to share a level crossing at the same time. 

All of this meant that it was crucial to understand what happened to avoid a repeat occurrence. And as ever, in order to do this, investigators had a series of questions to answer to explain the death of Jane Harding, and why the lives of every person on that train had been risked.

Firstly, The immediate cause. Why were cars and a train on the crossing at Moreton-on-Lugg at the same time? And once that immediate cause was identified, what had led to it taking place.

And secondly, one of the most important factors to consider, had there been any missed opportunities to prevent this accident? How could we prevent this happening again.

With the task laid out in front of them, they started to work.

 <Musical Interlude>

Why were there cars on the crossing?

To understand why cars ended up on the crossing at Moreton, we need to look at what process normally protected the line here. 

Moreton-on-lugg level crossing is an MCB crossing, A manually controlled barrier crossing. This means that the barriers at the crossing are, unsurprisingly, manually controlled by an adjacent signal box.

In the past, crossings could be physical gates controlled by the mark one human push and pull machine or mechanical solutions controlled with a wheel in the signal box, as this was up until 1975. At this point the gates at moreton were replaced with full width barriers, which reached across both lanes of the road, and that were controlled by a panel in the signal box.

When trains were approaching Moreton from the North, a certain process was to be followed;

The signaller at Moreton-on-Lugg is offered a train from Leominster by means of bell-code communication. If he can accept the train (because the previous train has cleared the block section), he sets his block instrument to ‘line clear’. When the train has passed the section signal at Leominster, LE27, the Leominster signaller then sends the bell code ‘train entering section’. 

The signaller at Moreton-on-Lugg acknowledges this, and sets his block instrument to ‘train on line’. 

The next indication of the approaching train is when it occupies track circuit B3 after the Dinmore tunnels. This sounds an audible alarm (known as an annunciator), which prompts the signaller to start the sequence of tasks that enable him to clear the signals for the approaching train. And this point is when the crossing comes in to play.

The sequence involves the signaller firstly checking that Moreton-on-Lugg level crossing is clear of road traffic and then holding down the ‘barriers lower’ push button on the control panel for the crossing, continuing to check as the crossing goes through its set closure sequence, until the barriers are fully down across the road. The sequence is 6 seconds of amber lights to road traffic, 8 seconds of red flashing lights before the barriers start to close, and by 21 seconds after the button is held, the barriers are down fully. 

We’ve covered interlocking before on the podcast, and it’s a great feature. It allows us to lock certain signals or equipment based on the settings of others.

On the approach to Moreton crossing from the north there were two signals, ML42, a stop signal on the immediate approach to the crossing and box, ML43, the home signal and ML44, the distant signal. In absolute block the distant being clear tells a driver that all of the stop signals are clear as well. The distant signal was interlocked against the stop signals, it could not be shown clear unless they were. 

To add to the safety here, all of the signals were interlocked against the barriers of the level crossing. Only after the barriers were closed could levers be moved in the signal box to reset the signals to clear, first ML42, then ML43 and finally ML44. 

This system means that had everything been working correctly, for the driver of 1V75 to be approaching on clear signals, the barriers had to have been closed. So why didnt they correlate? 

As part of the investigations the state of the signalling equipment was fully examined, including a review of how the crossing was looked after. As you might expect, the level crossing and its equipment were subject to regular maintenance and inspection. An examination of the maintenance records after the accident found all inspections were in date, and no work was recorded as outstanding. THere were no issues found with the equipment itself, the interlocking or the controls, so that ruled out the possibility of failure there leading to the collision. Both the signals and crossing were working as planned.

The biggest clue came from the account of the driver of the train, backed up by his trains forward facing CCTV. As he approached ML42, the signal protecting the crossing, it reverted to danger. This meant that the signal had been set correctly to clear but then placed back to danger, and not in enough time to slow the train down. In fact if it had been done 8 second later the train would have already passed the signal when it changed. This was not the only signal which changed from clear to danger as the train passed, but it was the only one the driver of V75 would have seen. When investigators viewed the forward facing CCTV of 1V75, they also viewed the cameras fitted to the rear cab. Shortly after the train passed the signal before ML42, ML43, the signal could be seen to move back to horizontal as well. In fact the two seemed to move almost in the reverse of what clearing them to proceed would look like. 

And there was a reason for this. 

The signals at Moreton had been manually placed back from clear to danger by Adrian Maund in the signal box. First he moved the levers needed to set the Distant, then ML43 back to danger, just after 1V75 had passed it. Shortly after this, Adrian placed the lever back to move ML42 back to danger, 8 seconds before the train reached it. 

The fact that signals were being replaced in this way definitely wasn’t in line with the rules and regulations governing signalling. But the most terrifying thing isn’t what he was doing, it’s why he was doing it. 

The interlocking at Moreton meant that you needed to replace all the approaching signals to danger before pressing the button which allowed you to raise the barriers at the level crossing. This was Adrian Maunds intention, and this is what he did. With 1V75 braking fully, but still approaching at over 60 miles an hour, Maund pressed the button which started the sequence to open the barriers. 

Over the next 7 seconds the barriers raised, the lights warning traffic extinguished, and car started to move out into the crossing. We all know what happened next. All due to an intentional action to open the crossing.

The immediate cause of the accident at Moreton-on-lugg was recorded as this;

The immediate cause of the accident was that the signaller raised the barriers at Moreton-on-Lugg level crossing when train 1V75 was closely approaching the protecting signal and unable to stop before reaching the crossing. This permitted the waiting cars to move onto the railway and into the path of the train.

So. We have our immediate cause, but it’s baffling as to why this happened. We need to dig deeper to find out why.

Luckily, Maund did not beat around the bush, hide the fact that he intentionally raised the barriers , or blame the equipment for failing. The simple reason he opened the barriers is because he mistakenly believed that he needed to raise them. He believed it was time to do so.

At around 28 minutes past 10, Adrian Maund noticed that the level crossing was still closed, and that cars were waiting. For some reason, assuming that he had left the barriers down in error, and that train 1V75 must have gone, he decided that he needed to open the crossing. He immediately began the task of replacing levers into the frame to allow this to take place. This is the reason that signals started to be put back to danger as the train was only just passing them, and the reason that the last one was thrown back in front of the train.

He released his error shortly after, around 7 or so seconds after he commanded the barriers to open. His que? He saw 1V75 approaching out of the corner of his eye. By this point the barriers were open, and cars had started to move out of the crossing. Maund desperately tried to right his mistake at this point, and the only tool in his arsenal was to close the crossing again. He pushed the “barriers close” button, but this was next to useless. The sequence which I described earlier takes nearly 14 seconds for the barriers to start lowering, and the cars entering the crossing had already driven past the lights so wouldn’t have seen them turn on again.

It should go without saying that a signaller has many duties. Physically pressing buttons and moving levers is one of them, but not the only one. A fairly crucial part is keeping track of where trains are within their section. Maund should not have lost track of where this train was, full stop. 

To understand why he did, we should look at what a normal transition through the area would have looked like. 

After accepting the train from Leominster, the signaller would be alerted by the annunciator which sounded a buzzer once a train occupied a specific track circuit on the approach. The signaller would then lower the barriers, which releases the interlocking for the signals on the approach. Those signals would be cleared in order, and then the signaller would watch this train traverse through the area on the track circuit displays above the lever frame. As the train proceeded through, the signaller could replace each signal to danger in turn, and when the train crossed in front of the signal box and over the crossing, the signaller could start the process to open the barriers. Nice and easy. 

So what had caused the experienced signaler to mess this up?

There are two very important words we need to be aware of here. Situational awareness. 

Signalers need to remain aware of what is going on in there area, and they need to do so whatever the situation might be around them. It’s clear Maund lost his situational awareness on the day. And why was this? It’s all to do with going back to the duties of the signaller.

This was not the only crossing that he was responsible for. Do you remember earlier in the episode when I talked about the farmer and his sheep stood to the side of the line? This was the very catchily named Ox Pasture Farm Number 1 UWC. A user worked crossing which required a phone call with the signaller to arrange crossing. 

This farmer had called up shortly before 1V75 passed, asking permission to cross his sheep over the line. He was told that a train was approaching, and to wait till after it was gone and call back. Maund dealt with this call without incident and returned to his task, monitoring trains through the section. 

The investigators reviewed the work undertaken by Maund on the day, and identified a number of tasks he was undertaking. 

The first task, and probably one of the most important, was monitoring the progress of 1V75 through the section. THis task however was interrupted. THe interruption? The telephone.

The farmer at the user worked crossing had called back again. Maund walked from the lever frame, to the back of the signal box and stood there trying to deal with the problem. At this point he has suspended the original task, needing to focus on a new one. 

Practice shows us that at this point it’s important to retain information from the original task, and ensure that we can return to it afterwards. 

This particular task did many things to distract Maund however. First and foremost, the requests to cross these crossings were few and far between, Prior to the accident, the signaller’s last recorded call from a user-worked crossing was on 5 September 2009. Hardly an everyday occurrence. 

Secondly, this wasn’t as clear cut a conversation as the first time, this time Maund needed to consider the train heading northbound. V75 was gone, past the crossing, but how much time was the farmer likely to need, versus how much time was available. This was the conversation taking place. All of this conversation being related to the other train, 1W85, meant that was now at the forefront of his mind. He was focused on a different train.

WHen you add in to this that he was aware that he needed to make sure that the correct paperwork was filled out and the right rules followed this. This task was so rare to Maund that he said he was trying to think back to recent briefings and recall the rules involved. 

Throughout this conversation, Maund was consulting a computer in the box, particularly a program known as TRUST. Train Running Under System TOPS. This is a system which is used to monitor train progress and record delays. Using this program during the call placed his back to the levers, and more importantly the lamps on the track circuit indicator board. 

When the call ended, a minute after it began, it also ended the second task. At this point what Maund should have done, is re-orientate himself to that first task. Recall the important information, and pick up where he left off. This did not happen. He didn’t go back to actively monitoring the progress of V75. In fact he almost did the opposite. He came back to the opposite side of the box, and reacted to the site of the cars still waiting at the barriers. Believing that the train had passed he opened the barrier. 

But why didn’t he manage to pick up where he left off? 

Investigators highlighted a few possibilities.

The signaller was away from his normal location when he went to the south end of the signal box after the second call from Ox Pasture Farm No.1 crossing. Because of this He was therefore deprived of his normal cues, the normal visual methods he used to track the process of trains, this may have disorientated him.

The second call from Ox Pasture Farm No.1 crossing was conversational and relatively long; it is credible that the signaller could have lost track of time, making it seem possible that train 1V75 had gone past in the meanwhile.

There was also consideration that the focus on the computer and TRUST might have further dismayed Maund from the fact that v75 had not yet passed him.

Whatever the real reason or whichever factor had most heavily influenced his mistaken belief, it was clear that he did, for a period of seconds, genuinely believe that 1V75 was past Moreton, and on it’s way towards Hereford. 

Human Error. A fatal mistake which was utterly avoidable, but which changed lives forever.

<Musical Interlude>

What could have prevented the accident taking place?

Interlocking prevented signals being cleared against the crossing when the barriers were open. This fantastic feature meant that trans should not have come barreling down the line towards and open crossing in day to day operation. This is a good safety system, and generally worked well, except for one thing. It was defeatable under the right conditions. 

When Maund threw back the signals to danger he satisfied the conditions to open the barriers of the crossing, despite the fact that a train was on its way, seconds away from the roadway.

We then need to ask ourselves whether or not there was a system available which could have plugged this gap. And so often like we get on this podcast, frustratingly, there was.

Approach Locking.

While the interlocking at Moreton-on-Lugg prevents the barriers being raised if the protecting signals are showing a clear indication, it does not stop the barriers being raised in error if a protecting signal is replaced to danger when the driver of a train approaching it is unable to stop before the level crossing. 

Approach locking is used to achieve this. Once the signaller has set the route and cleared the signal at the entrance, the signal interlocking prevents the opening of level crossings in the route ahead. 

In this condition the route is said to be ‘approach locked’, and, if the signal is then replaced to danger, the route stays locked unless;

• The signalling system detects that an approaching train has passed the protecting signal and entered the route; at which point the route ahead is locked by other means 
• Or until a preset time period has elapsed that gives reasonable assurance that an approaching train has come to a stand at, or before, the signal
• Or until there is proof that there is no approaching train.

This system would have prevented the actions of the signaller in this circumstance and could have saved the life of jane Harding. So why wasnt it fitted? Was it not available when the crossing was renewed in 1975? 

Again, frustratingly it was. THe system was developed in the 60s, so it existed at the time. 

But, The RAIB found no evidence of a regulatory requirement for British Rail to fit approach locking to the signals protecting the level crossing at Moreton-on-Lugg when the crossing was converted to manual barrier operation in 1975. There was no rule which said that these systems needed to be added. 

In fact there there was no industry requirement that mandated even a risk assessment to formally consider the safety benefit of fitting approach locking.

The last significant signalling renewal at Moreton-on-Lugg was the replacement of the original barrier equipment in 2009. 

When Network Rail was developing signalling designs against the initial remit for the renewal, there was discussion over the need to comply with the current, modern, standards. In addition to other work, the initial remit called for new barrier control panels that meant a change to the signalling plan. As a result, there was an early proposal to fit approach locking. 

However, it was eventually decided that the design should be developed without this. A risk assessment was to be done to support the decision, and a note was added to the draft signalling plan recording this fact.

However, around this time Network Rail confirmed that it became increasingly concerned about the cost of the design being developed, and had similar concerns about a number of other barrier renewal projects. It decided to look for an alternative, more cost-effective, approach. 

In the midst of all of this, the draft signalling plan was put aside and design work done against the initial remit was stopped; that risk assessment, the one to support not fitting approach locking, was not carried out.

Network Rail termed the alternative approach it developed the ‘partial renewal’. This enabled the old barrier units to be replaced with new units without the need for new barrier control

Circuitry. By adopting the partial renewal strategy, the standards did not require that formal

consideration be given to fitting approach locking.

No risk assessment was carried out to see whether or not the safety system should be added, nor did the industry mandate that one be undertaken. 

What it ultimately came down to, is that decision to limit signalling renewal work at Moreton-on-Lugg to like-for-like equipment replacement, as a strategy for improving value for money. 

As a direct consequence of this decision, there was no need to formally consider the benefits of an upgrade to bring the wider signalling system into compliance with current engineering standards, no need to consider or risk assess the lack of approach locking.

 <Musical Interlude>

Episode Conclusion – Memorial and poignancy please.

Recommendations were certainly handed out from the report into Moreton-on-lugg.

First and foremost was this;

Network Rail should identify level crossings operated by railway staff where a single human error could result in the road being opened to the railway when a train is approaching. At each such crossing, Network Rail should consider and, where appropriate, implement engineered safeguards. Safeguards for consideration should include additional reminder appliances, alarms to warn of the approach of trains, approach locking, locking of the route, run-by controls, and local interlocking of train detection and signalling systems with level crossing controls 

There were another 3 recommendations which were all handed to Network Rail as well, that they need to improve their level crossing risk management process, that they needed to develop criteria for when older equipment should be brought in line with current standards and that they needed to assess the risk that using TRUST and other systems could generate when used by signallers while in the commission of their duties.

In the aftermath of the report, Network Rail identified 54 similar crossings which were similarly at risk, and work was underway to rectify the problems.

Certainly not too little, but definitely too late.

In 2013 Mark Harding attended a trial at Birmingham Crown Court. The defendants were Adrian Maund and his former employer, Network Rail.

Both had denied breaching health and safety regulations.

As it happens, the court and the jury disagreed. Both Network Rail and the signalman were found guilty of failing to ensure the safety of Jane Harding.

On the 10th April both were sentenced.

Maund was fined £1,750 and sentenced to 275 hours unpaid work. Network Rail was fined £450,000 for failing to ensure the safety of the level crossing. In addition to the fines, Network Rail was also ordered to pay £33,000 towards prosecution costs, while Maund was told to pay £750.

One of the more crucial pieces of information in the trial was the cost of the approach locking as described by the prosecution. The equipment could have cost an extra £40,000, although Network Rail said the real cost could be much higher.

40 thousand pounds seems like nothing when it comes to saving a life. 

A normal day can turn to disaster in next to no time. Mark Harding did nothing wrong on the 16th January 2016. He stopped at a level crossing, obeyed the instructions and when the lights extinguished, and the barriers raised, he did exactly what he was supposed to do. He started to cross the crossing. He broke no rules.

His reward was serious injuries, a traumatic experience, and the loss of his beloved wife.

We can never take safety for granted, but at least we know that every incident like this helps to feed into a safer future for everybody going forwards.

<CREDITS>

Thank you as for tuning into episode 23.

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If you do want to support the podcast, get yourself over to signalstodanger.com, and either look at the support or shop pages.

Until next episode, Travel Safe!

https://assets.publishing.service.gov.uk/media/547c8ff3e5274a4290000191/R042011_110228_Moreton_on_Lugg_v2.pdf

https://www.bbc.co.uk/news/uk-england-hereford-worcester-21503798

https://www.railtechnologymagazine.com/Rail-News/sentencing-for-signalman-who-raised-barriers-in-level-crossing-crash-death

https://www.itv.com/news/central/story/2013-02-25/signalman-guilty-in-h-s-breach/

http://news.bbc.co.uk/1/hi/england/hereford/worcs/8464014.stm

https://assets.publishing.service.gov.uk/media/547c8ff3e5274a4290000191/R042011_110228_Moreton_on_Lugg_v2.pdfhttps://www.bbc.co.uk/news/uk-england-hereford-worcester-21503798https://www.railtechnologymagazine.com/Rail-News/sentencing-for-signalman-who-raised-barriers-in-level-crossing-crash-deathhttps://www.itv.com/news/central/story/2013-02-25/signalman-guilty-in-h-s-breach/http://news.bbc.co.uk/1/hi/england/hereford/worcs/8464014.stm