Colin Cameron
PFD Report
All Responded
Ref: 2019-0218
All 1 response received
· Deadline: 21 Aug 2019
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
21 Aug 2019
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
_ 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. Gloucestershire Coroner'$ Court; Corinium Avenue_ Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 coroner@gloucestershire gov.uk Katy
Responses
Response received
View full response
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.
• 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.
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_
Report Sections
Investigation and Inquest
On the 14th February 2017 commenced an investigation into the death of Colin Duncan Whistler Cameron The investigation concluded at the end of the inquest on the 12th June 2019. The conclusion of the inquest was a hybrid conclusion of accidental death and a narrative conclusion: The medical cause of death was IA 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 zih February 2017 he used the crossing in the morning as he drove to work at his campsite. vas 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. 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 high speed train travelling from Swindon, and approaching the crossing on the Down Line. Colin told the signaller that a train has passed 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 complete halt at 15.03.47 . The train driver raised the alarm. Emergency services attended, and pronounced Colin deceased at 15.33 hours_
Copies Sent To
Office of Rail and Road, HM Assistant Chief Inspector of Railways, One Kemble Street; London WCZB 4AN
British Transport Police , Bristol Temple Meads, Bristol BS1 6QF
gov.uk
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Remove all spikes and inward-facing constructions from perimeter and radial fences
Taylor Inquiry
Public Infrastructure Physical Hazards
Limit perimeter fencing height to a maximum of 2.2 metres
Taylor Inquiry
Public Infrastructure Physical Hazards
Provide sufficient 1.1-metre wide gates in perimeter fences for emergency evacuation
Taylor Inquiry
Public Infrastructure Physical Hazards
Paint and mark all emergency gates in fences with "Emergency Exit
Taylor Inquiry
Public Infrastructure Physical Hazards
Keep all perimeter fence gates to pitch unlocked and open during matches
Taylor Inquiry
Public Infrastructure Physical Hazards
Annually inspect all crush barriers for corrosion; repair or replace as needed
Taylor Inquiry
Public Infrastructure Physical Hazards
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.