Lxinfo - Accident investigation

Ireland’s independent Rail Accident Investigation Unit (RAIU) has concluded that a crossing keeper may have mistakenly opened a level crossing to road traffic as a result of having consumed cannabis.

The consequence of the crossing keeper opening the level crossing in Buttevant, Cork, to road traffic after one train had passed while another was approaching was that the second train struck the crossing gates at a speed of 64 kph. The incident occurred on July 2nd, 2011.

The RAIU has determined the cause to be that the crossing keeper did not fully adhere to the operation instructions provided for the opening and closing of the level crossing gates.
The contributory factors identified were:

The crossing keeper‘s co-ordination and concentration may have been affected by the presence of cannabis in his system
There was no engineered safeguard introduced at the level crossing to ensure that the crossing gates could not be opened to road traffic when a train was approaching, as the system was dependent on the full adherence of the gate keepers to the operation instructions.

The underlying factor was no formal risk assessment was carried out at the level crossing since its initial installation to measure its compliance against criteria introduced in Iarnród Éireann‘s (Irish Rail) current signalling standard.

From this investigation, the RAIU made two safety recommendations:

Irish Rail should identify similar manned level crossings where human error could result in the level crossing gates being opened to road traffic when a train is approaching; where such level crossings exist, Irish Rail should implement engineered safeguards; where appropriate
Irish Rail should review its risk management process for manned level crossings to ensure that risks are appropriately identified, assessed and managed to ensure that existing level crossing equipment is compliant with criteria set out in Irish Rail‘s signalling standards, where appropriate