Report by the Rail Accident Investigation Branch, August 2011

Some of the selected points from the report:

17.
The tanker driver
The branch line has a single track and only one train at a time is permitted to be on the branch. Track circuits are only provided at Marks Tey and Sudbury stations. Signallers, who control the branch line from Liverpool Street Integrated Electronic Control Centre (IECC), are able to maintain an overview of the branch line on a screen, but have no indication of exactly where the train is located when it is travelling between Marks Tey and Sudbury. A signal is provided at Marks Tey, which is cleared by the signaller for the departure of a train to Sudbury. There is no signal at Sudbury and the driver of a train returning to Marks Tey calls the signaller by telephone for permission to depart. If the signaller has given permission for a road vehicle to use one of the user worked crossings on the route after the train has arrived at Sudbury, but has not received a call back from the user to confirm that the vehicle has crossed safely, the signaller is able to warn the driver of the train accordingly so that he approaches the relevant location at caution.

22
The tanker driver had been qualified to drive LGV (Class 1) vehicles since June 1997. He started work as a LGV driver in Lithuania and entered the UK in 2005. The driver had been employed by JK Environmental since January 2006 and had previously worked for a parcel delivery company for 3 months. There was no requirement for him to retake a driving test in the UK to obtain a UK LGV licence because he originated from a country that is part of the European Union; a UK LGV licence is issued on completion of a form and submission of the LGV licence obtained in the driver's country of origin.
Events preceding the accident

28
The tanker driver started work at 06:00 hrs on 17 August 2010 and performed various driving duties (interspersed with periods when he was not driving) before starting his journey to the treatment works alongside Sewage Works Lane UWC. By the time he reached that location he had been on duty for 11 hours and driving for 6 hours.

29
At approximately 17:00 hrs the tanker approached Sewage Works Lane UWC and then travelled over the crossing. The tanker driver did not call the signaller for permission to cross on his inward journey. The loading of the tanker within the sewage works was completed by around 17:25 hrs and the driver prepared his vehicle for departure and then returned towards the crossing, proceeding through the crossing gates and reaching the railway line at 17:33:305 hrs.

30
Meanwhile, train 2T27 had departed from Sudbury at 17:31 hrs. At 17:33:14 hrs train 2T27 rounded a curve and Sewage Works Lane UWC came into view, approximately 490 metres distant. At this stage it is unlikely that the tanker was visible to the train driver because it was not yet on the crossing and the train driver's view of the western approach to the crossing was partially obscured by vegetation on the inside of the curve.

31
From this time onwards, the RAIB has not been able to establish an exact sequence of events because it is not known when the train driver first saw the tanker or at what speed the tanker was travelling as it approached the crossing and then drove onto it. The range of possibilities is discussed from paragraph 79 onwards. The remainder of this section contains the RAIB's assessment of the most likely sequence of events.

32
Approximately 8 to 10 seconds before the accident occurred, and with train 2T27 180 - 250 metres from the crossing, the train driver became aware of the front of the lorry approaching the crossing from the west side and then coming onto the railway. The train was travelling at 49.6 mph (79.8 km/h) at this time.

33
Realising that the tanker was not going to stop, the train driver applied the emergency brake 5 - 6 seconds before impact, when the train was approximately 120 metres from the crossing. The driver pushed the lever to sound the horn at around the same time as applying the emergency brake, but the RAIB has been unable to establish whether the horn actually sounded because its operation
is not one of the recorded functions on the On-Train Data Recorder (OTDR) installed on the Class 156 unit involved in the accident.

34
The train driver left his cab and shouted a warning to passengers within the ?rst carriage to advise them of the impending collision.

35
At 17:33:40 hrs the train struck the tanker while travelling at 41 mph (66 km/h). Several passengers and the conductor were injured during the accident. Their injuries ranged from minor cuts and bruises to serious abdominal injuries. The train driver was thrown against the headwall of the vestibule area of the leading coach and suffered serious injuries.

36
The point of impact on the tanker was approximately 5 metres from the front of the tank and approximately 8.5 metres from the front of the tractor unit. The tractor unit detached from the trailer as a result of the impact and the tank being conveyed on the trailer was breached, causing the contents to cascade over the train. The front of the leading coach of the train was severely damaged by the impact and the coach derailed, but remained upright at an angle, stopping approximately 35 metres beyond the crossing. The rear coach remained on the rails but suffered minor external damage. Both coaches had internal damage to doors, tables and ?xings with some of the damage arising from passenger impact. The derailed coach damaged a short parapet alongside the track, with diesel fuel and ef?uent spilling into a pedestrian/cattle underpass below and onto the track.

37
Shortly after the train stopped, the train driver made an emergency call from his mobile telephone and advised the signaller at Liverpool Street IECC of the accident. The signaller contacted the emergency services. Between 17.35 hrs and 17.47 hrs various other emergency calls were made from passengers on the train to the emergency services, with the ?rst response units arriving on site at 17:40 hrs.

38
All of the passengers and train crew were evacuated in a controlled manner and people who had been injured were taken to hospital by land or air ambulance.

41
The tanker driver did not use the telephone before crossing the line, although the signs at the crossing indicated that anyone crossing with a vehicle should telephone the signaller before doing so. This was a causal factor in the accident.

53
The long waiting time that road vehicle users sometimes experienced at the crossing before being given permission to cross led to a high level of non-compliance with the correct procedures for using Sewage Works Lane UWC. This was an underlying factor in this accident.

54
Road crossing users might have to wait up to 19 minutes before being given permission by the signaller to cross the line at Sewage Works Lane UWC. This provided a disincentive for them to telephone the signaller before crossing.

55
Witness evidence indicates that some authorised users were frustrated by the length of time that they had to wait on occasions when crossing with a road vehicle at Sewage Works Lane UWC. The branch is not track circuited and
the signaller only knows when the train is at Marks Tey or Sudbury stations. Consequently, the signaller can only give road vehicle users permission to cross under the circumstances described in paragraph 43.

159
No single person or team in Network Rail had a complete understanding of the risk at Sewage Works Lane UWC. This was an underlying factor in the accident.