Summary

At 06:09 hrs on 21 October 2021, a passenger train travelling at 123 mph (198 km/h) struck a hand trolley on the track near Challow, Oxfordshire. The train was the first to pass through the area after the completion of overnight maintenance work. There were no injuries among the passengers or crew on board and the train did not derail. The hand trolley was destroyed by the impact and debris from it caused damage to equipment under the train. The collision also resulted in minor damage to the track.

A maintenance team had carried out overnight work at Challow and no one noticed the team had left its hand trolley on the track. The checks undertaken before handing back the railway for normal operation also had not identified the hand trolley’s presence. A process which formed part of these checks was the line clear verification process. It was used to monitor what vehicles, including hand trolleys, were placed on and taken off the track during the overnight work. However, there were weaknesses within this process, and these were compounded by the maintenance team not following the process as it was required to on the night concerned.

Underlying factors related to the weaknesses within the line clear verification process were:

• It was reliant on human actions for its successful implementation, which the rail industry had recognised, but not yet implemented any measures to avoid or mitigate errors.
• It was separate to the work planning process as defined by Network Rail’s company standards. This was a possible underlying factor.
• Network Rail’s assurance activities had not detected that staff in the Swindon delivery unit welding and grinding section were not complying with the line clear verification process. This was a possible underlying factor.

A further probable underlying factor was that hand trolleys were being routinely used at night without displaying any red lights and that no assurance activities were taking place within work sites to monitor compliance to this requirement.

RAIB observed that after the accident, the train was allowed to travel at a speed above that which should have been permitted given the level of damage it had sustained. RAIB also observed that there were multiple issues with how the work at Challow was planned by Network Rail.

Recommendations

RAIB has made five recommendations to Network Rail. The first is to establish how the existing line clear verification process can be improved while the second is to consider what technology could be used by its staff to support the process. The third recommendation is to propose an amendment to the Rule Book so that hand trolleys are required to display an illuminated red light in both directions at all times when on the track. The fourth is for Network Rail to have processes in place to ensure that any hand trolley placed on its track has illuminated red lights displayed in both directions. The fifth recommendation is to review the effectiveness of its safety assurance activities which check that hand trolleys are being used correctly and safely.

RAIB also identified three learning points. The first reminds maintenance staff about the importance of complying with all rules and standards concerning how trolleys and rail skates should be used on Network Rail’s infrastructure. The second highlights the importance of clear communication between the staff at a train involved in an accident and those based in control rooms to establish what damage has been sustained by a train, so that the appropriate controls can be put in place before the train is permitted to move. The third is that staff involved in planning maintenance work produce documents that are accurate, appropriate and specific for the task that is being carried out, and involve those responsible for the work in the planning of it.

Andrew Hall, Chief Inspector of Rail Accidents said:

Systems and processes designed to detect any equipment left on the track before lines re-open after maintenance work, should not be reliant solely on human performance in the middle of a dark night. There are technological solutions which can assist with addressing this issue, and this accident is an example of an opportunity missed.

Our investigation found that the railway had identified the risk of equipment, such as hand trolleys, being left on the line and that it could mitigate this risk by improving the line clear verification process. However, it had not yet implemented the changes required when this accident occurred. This meant that the process remained vulnerable to human error. In this case, this vulnerability was made worse because relevant procedures were not followed correctly. Technology has an important role to play in improving the safety of the railway and it is important that the development of solutions to better support staff are prioritised.

It is also a concern that hand trolleys were routinely being used on the track at night without displaying red lights. But it is of equal concern that no activity to monitor this requirement was being undertaken. Once again, assurance activities intended to check that rules are being followed and that processes are being implemented correctly were not effective.

Notes to editors

1. The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.

2. RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.

3. For media enquiries, please call 01932 440015.

Newsdate: 13 October 2022

Summary

At 06:09 hrs on 21 October 2021, a passenger train travelling at 123 mph (198 km/h) struck a hand trolley on the track near Challow, Oxfordshire. The train was the first to pass through the area after the completion of overnight maintenance work. There were no injuries among the passengers or crew on board and the train did not derail. The hand trolley was destroyed by the impact and debris from it caused damage to equipment under the train. The collision also resulted in minor damage to the track.

A maintenance team had carried out overnight work at Challow and no one noticed the team had left its hand trolley on the track. The checks undertaken before handing back the railway for normal operation also had not identified the hand trolley’s presence. A process which formed part of these checks was the line clear verification process. It was used to monitor what vehicles, including hand trolleys, were placed on and taken off the track during the overnight work. However, there were weaknesses within this process, and these were compounded by the maintenance team not following the process as it was required to on the night concerned.

Underlying factors related to the weaknesses within the line clear verification process were:

• It was reliant on human actions for its successful implementation, which the rail industry had recognised, but not yet implemented any measures to avoid or mitigate errors.
• It was separate to the work planning process as defined by Network Rail’s company standards. This was a possible underlying factor.
• Network Rail’s assurance activities had not detected that staff in the Swindon delivery unit welding and grinding section were not complying with the line clear verification process. This was a possible underlying factor.

A further probable underlying factor was that hand trolleys were being routinely used at night without displaying any red lights and that no assurance activities were taking place within work sites to monitor compliance to this requirement.

RAIB observed that after the accident, the train was allowed to travel at a speed above that which should have been permitted given the level of damage it had sustained. RAIB also observed that there were multiple issues with how the work at Challow was planned by Network Rail.

Recommendations

RAIB has made five recommendations to Network Rail. The first is to establish how the existing line clear verification process can be improved while the second is to consider what technology could be used by its staff to support the process. The third recommendation is to propose an amendment to the Rule Book so that hand trolleys are required to display an illuminated red light in both directions at all times when on the track. The fourth is for Network Rail to have processes in place to ensure that any hand trolley placed on its track has illuminated red lights displayed in both directions. The fifth recommendation is to review the effectiveness of its safety assurance activities which check that hand trolleys are being used correctly and safely.

RAIB also identified three learning points. The first reminds maintenance staff about the importance of complying with all rules and standards concerning how trolleys and rail skates should be used on Network Rail’s infrastructure. The second highlights the importance of clear communication between the staff at a train involved in an accident and those based in control rooms to establish what damage has been sustained by a train, so that the appropriate controls can be put in place before the train is permitted to move. The third is that staff involved in planning maintenance work produce documents that are accurate, appropriate and specific for the task that is being carried out, and involve those responsible for the work in the planning of it.

Andrew Hall, Chief Inspector of Rail Accidents said:

Systems and processes designed to detect any equipment left on the track before lines re-open after maintenance work, should not be reliant solely on human performance in the middle of a dark night. There are technological solutions which can assist with addressing this issue, and this accident is an example of an opportunity missed.

Our investigation found that the railway had identified the risk of equipment, such as hand trolleys, being left on the line and that it could mitigate this risk by improving the line clear verification process. However, it had not yet implemented the changes required when this accident occurred. This meant that the process remained vulnerable to human error. In this case, this vulnerability was made worse because relevant procedures were not followed correctly. Technology has an important role to play in improving the safety of the railway and it is important that the development of solutions to better support staff are prioritised.

It is also a concern that hand trolleys were routinely being used on the track at night without displaying red lights. But it is of equal concern that no activity to monitor this requirement was being undertaken. Once again, assurance activities intended to check that rules are being followed and that processes are being implemented correctly were not effective.

Notes to editors

1. The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.

2. RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.

3. For media enquiries, please call 01932 440015.

Newsdate: 13 October 2022

The UK will donate cutting edge air defence missiles to Ukraine which can help protect against Russian missile strikes, the Defence Secretary announced today.

The AMRAAM rockets, which will be provided in the coming weeks for use with the NASAMS air defence systems pledged by the US, are the first donated by the UK which are capable of shooting down cruise missiles.

The rockets will help to protect Ukraine’s critical national infrastructure, with the announcement coming days after Russian missiles struck civilian targets in cities across Ukraine.

Hundreds of additional air defence missiles, of other types previously provided, will also be donated as part of the package, along with hundreds of additional aerial drones to support Ukraine’s information gathering and logistics capabilities, and a further 18 howitzer artillery guns, in addition to the 64 already delivered.

Bolstering Ukraine’s air defences has been and remains a priority for UK military support. So far we have provided a variety of air defence systems including Stormer vehicles fitted with Starstreak launchers, and hundreds of anti-air missiles.

Ben Wallace announced the latest tranche of equipment ahead of a meeting of NATO Defence Ministers in Brussels today (Thurs 13 Oct), where Allies met on the sidelines yesterday to discuss further support for Ukraine. It also comes as Ukraine prepares to honour veterans and fallen soldiers on Defenders Day tomorrow (Fri 14 Oct).

Defence Secretary Ben Wallace said:

Russia’s latest indiscriminate strikes on civilian areas in Ukraine warrant further support to those seeking to defend their nation. So today I have authorised the supply of AMRAAM anti-aircraft missiles to Ukraine.

These weapons will help Ukraine defend its skies from attacks and strengthen their overall missile defence alongside the US NASAMS.

The UK will also give £10 million to NATO’s Comprehensive Assistance Package for Ukraine. The funding will help to provide urgent non-lethal assistance to Ukraine such as winter clothes, shelters, generators, fuel trucks and ambulances for the Ukrainian Army ahead of the winter.

The Defence Secretary will urge his Allied counterparts to continue to support Ukraine for as long as it takes. They will review the implementation of decisions taken at the Madrid Summit designed to strengthen NATO’s collective deterrence and defence. This will be the first time that Finland and Sweden will attend as official invitees.

They will also discuss defence industrial capacity, to ensure that Allies are able to increase stockpiles of munitions so that we can keep supporting Ukraine, while remaining ready to defend NATO territory.

Defence Ministers will speak about the recent sabotage of the Nord Stream pipelines, as well as how the Alliance can safeguard critical infrastructure from future attacks.

NATO Allies have stepped up their presence in the Baltic and North Seas in response to the attacks, increasing security around key infrastructure across multiple domains, including with satellites, ships, submarines, maritime patrol aircraft, and anti-drone systems.

Thank you, Mr. President. I’d like to thank SRSG Ruiz Massieu, Ms Moreno, and Ambassador Muhith for their briefings. And I give a warm welcome to welcome Foreign Minister Leyva and Ambassador Zalabata to the Council today. Their presence with us is a reflection of their personal commitments to the peace process, and to working in partnership with this Council. So let me make three remarks today.

Firstly, the United Kingdom welcomes the renewed momentum for peace in Colombia. The new Government’s commitment to implementation of the peace agreement was clearly demonstrated through President Petro’s attendance at the first meeting of the Commission for the Follow-Up, Promotion and Verification of the Implementation of the Peace Agreement (CSIVI) and the National Commission of Security Guarantees on 2 October. We commend the Government’s focus on vital rural reforms including the intention to accelerate the titling and purchase of land. We note the progress made by the Special Jurisdiction for Peace with the opening of three new cases and with another due to be opened on Sexual and Gender based violence.

Second, we encourage the Government to keep emphasis on the comprehensive implementation of the agreement, despite the challenges. We remain deeply concerned by the ongoing threats and violence faced by former combatants and human rights defenders. We welcome the swift action taken by the Government to set up 14 command posts as recommended by the Emergency Protection Plan. It is clear that further security initiatives are urgently needed. We welcome the new government’s further commitment to making further progress on implementing the gender and ethnic provisions of the agreement including on land ownership.

Third, Mr. President, we recognise the complexity of the instability in Colombia and the need for a multi-dimensional approach to address violence and ensure human security.  In this light, the UK welcomes the progress made towards reinitiating talks with ELN.  We hope that the delegations to peace talks will be representative and that lessons will be learned from the process which led to the 2016 agreement.

The United Kingdom also welcomes Colombia’s commitment to reinforce international cooperation to tackle narco-trafficking and bring to justice those that profit from the misery of the drugs trade, in both producer and consumer countries.

Finally, President, let me reaffirm the United Kingdom’s support to Colombia and to the Colombian people who remain committed to implementing the peace agreement despite the many challenges they face. In particular we look forward to working with Colombia, the UN and our co-penholder Mexico on the upcoming renewal of the UN Verification Mission’s mandate. Thank you.