Executive summary
On 23 December 1993 as Train 573 approached the London Street level crossing near Eltham the crossing alarms did not activate until the train was very close to the roadway. The Locomotive Engineer reported the incident as an alarm malfunction, but the investigation revealed that the alarms should have been reset manually after a train crossing at nearby Eltham Yard. The safety issues identified in this investigation were a deficiency in the route familiarisation certification of Locomotive Engineers, and an incorrect instruction in the Working Timetable, and a deficient safety culture among operating staff.
Related Recommendations
They take positive steps to encourage a safety culture among Locomotive Engineers and other operating staff in which events which are not understood, and apparent faults or errors are promptly reported, openly discussed and solutions disseminated.
They review the wording of clauses 3.8.4 and 3.8.5 of section L4 of the Working Timetable with a view to explaining clearly the situation which arose in this incident i.e. the need to reset the alarms if sequential berthing on the main line and loop occur at Eltham, and the crossing alarms cancel after the passage of the northbound train.
For resetting the alarms at Eltham, to obviate the need for the Locomotive Engineers to leave the cab to reset them.
They reiterate to Locomotive Engineers that "crashing" alarms to operate them is not an acceptable practice, and that it may lead to unreliable or unexpected results.
They review the methods of section familiarisation training, with a view to establishing syllabi and examinations that are documented and able to be audited.
They investigate the practicability of introducing an operating procedure that, when trains are to cross at Eltham, requires one train to stop outside the limits of the track circuits for the Bridge Street and London Street level crossing alarms until the other train has berthed and advised that the train is in the siding clear of the fouling boards.