UK Inquiry Tracker

Emma Lifsey

PFD Report Historic (No Identified Response) Ref: 2014-0204

Date of Report 7 May 2014

Coroner Heida Connor

Coroner Area Nottinghamshire

Response Deadline ✓ from report 3 July 2014

Railway related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

The coroner noted that old-style filament bulbs in wig wag lights at the Beech Hill crossing were less than half as bright as they should have been and that the replacement of these lights with LEDs at level crossings was taking too long, given the known issue of sun glare affecting signal visibility.

View full coroner's concerns

We heard evidence from several witnesses about the effect of glare – both directly from the low sun and reflected from the road surface – and how this may have affected the visibility of the wig wag lights in particular.

We heard that the wig wag lights at Beech Hill crossing had old-style 36W filament bulbs. The optical consultant described these lights as being “the worst he had seen”, and less than half as bright as they should have been. Network Rail witnesses gave evidence about changes being implemented. In particular, we heard of the decision to change all 36W lights at level crossings to LED lights. We were told that 494 level-crossings have been identified as having the old-style lights. This information was available in December 2013. To date, 58 have had the lights changed to LEDs. The current plan, we were told, was to complete this by October 2015.

We were also told that Network Rail is considering commissioning research into the effect of glare on signals.

I heard evidence (in the absence of the jury) about RAIB recommendations made after collisions at Wraysholme in 2008, and Halkirk in 2009. These incidents were not identical factually to the collision at Beech Hill, but it is clear that the issue of sun glare and visibility of signals is not a new one.

I noted at the inquest that Network Rail is seeking to reduce these risks, but my concern relates to timescale. The proposed changes and research are simply taking too long, and I am concerned that this risk will not be reduced quickly enough to avoid further tragedies.

Sent To

Network Rail

Response Status

Linked responses 0 of 1

56-Day Deadline 3 Jul 2014

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 7 December 2012 I commenced an investigation into the death of Emma Lifsey, DoB 1 September 2008. The investigation concluded at the end of the inquest on 1 May 2014. The conclusion of the jury at the inquest was :

Medical cause of death : traumatic brain injury

Narrative conclusion : The conclusion of the death of Emma Isabel Lifsey is due to accident.

Circumstances of the Death

Emma Lifsey was a 4 year old girl, travelling as a passenger in the rear seat of a car driven by her grandmother, on Springs Road, on the approach to Beech Hill level crossing, near Finningley, North Nottinghamshire, on 4 December 2012. gave evidence that she did not see the barrier or the wig wag lights at the automatic half barrier crossing until it was too late, and drove into the path of a train. Emma died the following day. sustained serious injuries, but survived.

Action Should Be Taken

I ask that you consider expediting the following :

1. Replacement of all 36W bulbs with LEDS at level crossings – currently scheduled to be completed by October 2015.
2. Research into determining objective criteria that those inspecting crossings can use to determine :
a. How signal performance and the effect of glare can be objectively assessed in the field.
b. How to set up a programme for keeping this under regular review.
c. How to assess which crossings are most affected by sunlight and glare.

In your response, I invite your commitment to clear, achievable deadlines.

Copies Sent To

3. RAIB 4. ORR