Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0218, written 26 Jun 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Jun 2019 |
|---|---|
| Reference | 2019-0218 |
| Deceased | Colin Cameron |
| Coroner | Katy Skerrett |
| Coroner area | Gloucestershire |
| Category | Railway related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
H M Senior Coroner for Gloucestershire Ms Katy Skerrett REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Network Rail, The Company Secretary, Network Rail Infrastructure Ltd, 1 Eversholt Street, London NW1 2DN CORONER | am Katy Skerrett, Senior Coroner for Gloucestershire. CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On the 14" February 2017 | commenced an investigation into the death of Colin Duncan Whistler Cameron. The investigation concluded at the end of the inquest on the 12” June 2019. The conclusion of the inquest was a hybrid conclusion of accidental death and a narrative conclusion. The medical cause of death was 1A multiple blunt force injuries to head and trunk. CIRCUMSTANCES OF THE DEATH Colin Cameron “Colin” was a 60 year old, who was long term authorised user of the Frampton Mansell user worked crossing. On the 7" February 2017 he used the crossing in the morning as he drove to work at his campsite EEEEEEVas his passenger. At approximately 1500 hours he was making the return journey crossing from the north side of the track from the Sapperton village direction, heading south towards Frampton Mansell. IEEE exited the vehicle, and opened the gates on both sides of the crossing. At 15.02 hours Colin called the signaller to request permission to cross. The signaller was aware that there was a train in the track section containing the crossing. This was a high speed train travelling from Swindon, and approaching the crossing on the Down Line. Colin told the signaller that a train has passed a couple of minutes earlier. No train had passed. The signaller relied upon Colin’s statement and gave permission to cross. The train driver saw Colin's vehicle enter the crossing and applied his emergency brakes. The train impacted with the vehicle at 15.03.20. Colin's vehicle was stuck under the train. The train came to a complete halt at 15.03.47. The train driver raised the alarm. Emergency services attended, and pronounced Colin deceased at 15.33 hours. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — 1. Whether sufficient consideration has been given to address the absence of any instructions to signallers on how to extract information from the user, and 2. Whether the relevant authorities and persons authorised to use this crossing have given sufficient consideration to whether this crossing can be closed. Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | coroner@gioucestershire.gov.uk [6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are 2 under a duty to respond to this report within 56 days of the date of this report, namely by 4pm 28" August 2019. |, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent.a copy of my report to the Chief Coroner and to the following Interested Persons (1) ae (2) Office of Rail and Road, [EE HM Assistant Chief Inspector of Railways, One Kemble Street, London WC2B 4AN (3) British Transport Police, HMM Bristol Temple Meads, Bristol BS1 6QF (4) RAIB, The Wharf, Stores Road, Derby, DE21 4BA lam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Ms K Skerrett Senior Coroner for Gloucestershire Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3D) Tel 01452 305661 | coroner@gloucestershire.gov.uk
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
NetworkRail "1"144.11W11 Network Rail Western House 1 Holbrook Way Swindon SN1 1BD Mrs Katy Skerrett H M Senior Coroner for Gloucestershire Gloucestershire Coroner's Court Corinium Avenue Barnwood Gloucester GL4 3DJ 19 August 2019 Dear Madam Regulation 28 Report following the inquest touching the death of Mr Colin Duncan Whistler Cameron On behalf of Network Rail, I write to thank you for your Regulation 28 report dated 26th June 2019 and to respond to the concerns raised. Your report concerns the death of Mr Colin Duncan Whistler Cameron who sadly died when he was struck by a train at Frampton level crossing on 7th February 2017. I hope that my response addresses the concerns raised as follows: Whether sufficient consideration has been given to address the absence of any instructions to signallers on how to extract information from the user: and. Whether the relevant authorities and persons authorised to use this crossing have given sufficient consideration to whether this crossing can be closed. This first concern refers to there being an absence of any instructions to signallers on how to extract information from a level crossing user. However, the evidence presented at the Inquest highlighted that instructions are provided to signallers. The Inquest heard evidence that the signaller is required to follow the railway industry Rule Book GE/RT 8000, Module TS9 'Level crossings — signallers' regulations', issue 3 dated 05/12/2015. Section 2.1 of those regulations applies to user-worked crossings with telephones (UWC+Ts), such as that at Frampton, and in respect of instructions to the signaller states: When you receive a telephone call from the crossing, you must find out.- • Which crossing the user wants to use • What is required to pass over the crossing • How long it will take. If there is enough time for the crossing to be used before the next train passes over it, you must, except as shown in regulation 2.1.24. tell the user to use the crossing immediately. If there is not enough time, you must tell the user to wait and telephone again. Network Rail Infrastructure Limited Registered Office. Network Rail. One Eversholt Street. London. NWT 20N Registered in England and Wales No 2904587 'WNW networkrail This method of working is straightforward and has been in place and safely used for many years. It provides the signaller with the information they require to make a decision on whether it is safe to cross. The Inquest also heard evidence that the signaller receives local training on the signal box they operate, and this includes information on each crossing on a line of route. The instructions cover all additional or amended specific methods of working for each crossing, and provide the signaller with the local information to assist them to make decisions on whether or not it is safe to cross. Signalling locations are also issued with UWC+T 'prompt cards' which also outline the requirement for the signaller to identify the level crossing the user wants to use, what the user is crossing with and how long this will take. The signaller training focuses on technical skills, but is also heavily focused on non-technical skills. Some of the most relevant non-technical skills include planning & decision Making, communications, multi-tasking, relationships with people and attention management. The signaller training and ongoing capability management focuses on the delivery of safety critical communications. Network Rail has adopted the industry best practice safety critical communications training (produced by the Railway Safety & Standards Board) into the initial signaller training and ongoing operational development days. This training, together with the non-technical skills, provides the signaller with the tools and capability to gather the information required to make a safe decision. It is not accepted therefore that there is an absence of instruction to signallers on how to extract information from the user and it is not accepted that the signaller failed to extract relevant information from the user on this occasion. It is deeply regretted that the information provided by the user on this occasion was inaccurate. With regard to the second concern raised, level crossings represent the highest risk on the railway and Network Rail always seeks to close crossings wherever possible. Since 2009 Network Rail has closed 1203 level crossings. Network Rail does not have unilateral powers to close level crossings as many have public or private rights. Closure of a user-worked crossing such as Frampton requires the consent of the authorised users. Efforts to close Frampton crossing in the past have been unsuccessful. After making renewed enquiries since the inquest, we believe there to be one authorised user of the vehicular level crossing at Frampton. This individual is under no legal obligation to release their rights and Network Rail cannot compel them to do so. Demands for compensation for the release of these rights must be proportionate and give due consideration to the use of public money. Network Rail has therefore given considerable consideration to the closure of this and other crossings of its type and would ideally wish to do so if the law and / or the users would permit it. Since the Inquest, Network Rail has written to the authorised user asking them to consider releasing their rights to the crossing. In so doing it has referred to the concerns raised by the Coroner and offered to discuss reasonable compensation. If agreement is reached with the user, the crossing can and will be closed to vehicles within a relatively short period of time. The crossing would then remain as a public bridleway only as the crossing is also a public right of way. Network Rail has written to the public rights of way officer at Gloucestershire County Council to consider the feasibility of extinguishing or diverting the bridleway where it crosses the railway. However, there are significant difficulties associated with extinguishing or diverting public rights of way, and any proposal to do so can be subject to a public inquiry. Network Rail can present evidence to support closure at such an inquiry, but the outcome is not one that Network Rail can control. Notwithstanding these difficulties, Network Rail will do all it reasonably can to remove the vehicular rights at the crossing and, in association with the Council public rights of way officer and with public support, will do all it reasonably can to divert the bridleway so the crossing can be completely closed. Yours sincerely Mike Gallop Route Director, Wester
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