A ROUTINE Saturday afternoon trip to Cambridge for Christmas shopping ended in tragedy for two teenagers on December 3 2005 when they were hit by a train at Elsenham station, close to London Stansted airport.
What was initially cited as a tragic accident in a court tribunal held in 2007 was eventually found to be the fault of Britain's infrastructure manager, Network Rail (NR). The case was reopened in 2011 following the discovery of a previously unseen 2002 risk assessment document which recommended locking gates to the station's pedestrian level crossing. NR overlooked this request at the time and was forced to pay a £1m fine and court costs in March 2012 after pleading guilty to three offences brought for failing to carry out an adequate assessment of the risks at the crossing.
The accident occurred after the girls opened the manual gate and walked onto the tracks while the crossing sirens were still sounding. They thought the siren was for the Cambridge-bound train that they wanted to catch, and had already passed the crossing. It was at this point that they were hit by a second passing train that was travelling through the station from Birmingham to Stansted Airport. They were killed instantly.
A scathing analysis presented to the court by safety specialist Dr Tony Cox of the final risk assessment of the level crossing conducted eight months before the accident found that the assessment neglected to show that the level crossing in question had extremely short visual sighting times. The low-frequency of off-peak services also created an incentive to catch immediately departing trains, while the positioning of ticketing facilities on only one platform at the station meant that passengers often had to use the crossing more than once.
Cox estimated that there was a "near miss" at the crossing at least once a week, adding that the failure to warn passengers of the passage of a second train was a very significant factor in the two girls' deaths and a huge failure of the level crossing system in place.
Reacting to the verdict, NR chief executive Sir David Higgins made a pledge to the girl's families to improve level crossing safety. "Fundamental changes to the way we manage and look after the country's more than 6500 level crossings, have been, and are being, made," Higgins said.
Indeed, NR is now engaging in a £130m programme to address level crossing safety across the country by eliminating as many crossings as possible, improving the risk assessment process, and installing technology that will enhance public safety.
Mr Martin Gallagher, NR's head of level crossings, and the man charged with rolling out the level crossing programme, says that Higgins made it clear that he wanted to avoid incidents like those at Elsenham immediately after taking on the chief executive's role in 2011. An extra £90m was soon allocated to the programme in addition to £40m secured in 2009.
"I went into his [Higgins'] office and he had a newspaper in front of him about the court proceedings which followed the deaths of the two girls," Gallagher says. "He said he wanted to make this his number one priority and that he wanted a plan to sell to the executive that would fix the problem. This was a significant moment for the programme to get the funding we needed to meet the target of reducing the number of active level crossings by 25%, and to instigate a dramatic change to the way Network Rail manages level crossings in Britain."
Gallagher says that rather than taking a reactive approach to media headlines and managing risk at crossings, NR now has a clearly-defined strategy which is aided by support from the very top of the organisation.
He says he took heed from the oil and gas industry, which changed its approach to risk management in safety-critical environments following a series of accidents in the 1970s. As a result there are two key areas in which level crossing safety is being addressed: improving the organisational capacity to manage risk, and adopting and implementing a standardised nationwide programme to both reduce risk at level crossings and increase education and awareness of the potential dangers.
"One of the most problematic areas to argue in favour of adopting this policy is that in terms of safety we have a good record at level crossings," Gallagher says. "Not that many people die at level crossings in Britain. There is an argument as a result that if not that many people are being killed then it is not a problem and it is something that does not need to be addressed.
"However, this drives complacency and adds to the idea that it is the fault of pedestrians and motorists, and that we don't need to do anything. Only when there is an unfortunate event like Elsenham are we alerted to the system's failings. Our business case then is not just based on how much it is going to cost and the number of lives we might save, but on reducing the risk factor and the fact that it is the right thing to do."
At the heart of this strategy is the appointment of 100 specially-trained level crossing managers. Each manager is assigned a region where they undertake risk assessments and asset inspections and carry out minor maintenance at their pre-designated level crossings.
They carry handheld devices on which they conduct risk assessment reports at the work site, eliminating the previous inefficient paper-based assessment system. The inspectors make decisions on risk mitigation measures at a crossing, and work with the local community to improve education.
A major emphasis of their work is to identify crossings for elimination. NR has already closed over 600 crossings since 2009, which has saved an estimated lifetime operational cost of £158m, and is on target to close 150 more by 2014, achieving a further saving of £50m. An additional 500 level crossings are earmarked for closure in 2015-2019.
New footbridges are among the solutions used to eliminate pedestrian use of level crossings with 55 low-cost foot bridges installed the past two years. Gallagher says that by instituting a national programme to identify when a bridge might be appropriate, NR can buy in bulk which has reduced the cost of procurement by around £500,000.
In instances where a crossing cannot be closed, the infrastructure manager is trialling and introducing a variety of new safety features to reduce risk for users. The simplest of these is improving the line of sight at level crossings which involves cutting back vegetation and has now been carried out at 1100 locations.
New technology is also playing a major role. For example, spoken warning systems, which announce that "another train is coming" rather than change the tone of the warning siren, which is potentially confusing to the public and arguably led to the accident at Elsenham, will be installed at 151 crossings by the middle of next year.
Low-cost barriers have similarly been installed at 72 open crossings. To the user these appear no different than a conventional half barrier crossing, but they cost around £100,000 compared with £850,000 for a full upgrade from an open crossing. Low-cost miniature red and green warning lights, which are designed to reduce waiting times and incidents of misuse, are also being installed, along with automatic gate open and closure systems at 500 level crossings.
Various camera types are now playing a major part in reducing risk. NR, in cooperation with the British Transport Police, will install 150 fixed enforcement cameras at road level crossings by next year, while 15 mobile safety vehicles which issue penalty notices to people who misuse crossings are now in use.
Cameras are similarly being used for census gathering at 650 open level crossings to build an accurate usage profile that will better inform the risk assessment process. In addition, special cameras with video analytics technology which can detect when an object is stationary on the track and can directly inform the train operator of the potential risk have been installed.
NR has introduced similar obstacle detection technology at 200 locations. This uses both radar and lidar optical remote sensing system to detect whether an object is crossing the track and communicates with the signalling system to turn signals to danger if an object is detected, which is a first for the British railway network.
Similarly on the Marks Tey - Sudbury line in eastern England a GPS system is providing users with up-to-the-minute information on precise train location so that they know when it is safe to use the level crossing, avoiding unnecessarily long waiting times.
"Often people can wait up to 20 minutes to use this level crossing because it is a single-track line that has a significant distance between signals," Gallagher says. "In the 21st century we should be able to detect where trains are to inform people when it is safe to use a level crossing so they are not left waiting for this amount of time."
Since the programme began, Gallagher says that NR has reduced its level crossing accident risk factor by nearly 20% meaning that level crossings are now arguably safer than they have ever been. The life-cycle cost savings achieved also mean that the programme is effectively paying for itself.
But with three years to go until the risk assessment programme is completed, and with new technology being installed all the time, Gallagher is hopeful of achieving more. If this is the case, tragedies like Elsenham will increasingly become a distant memory.
"When we complete our programme of analysis of risk assessment at every level crossing in the country in 2015 I expect to see that every one of them will have a higher level of safety and asset quality than we have ever seen before," Gallagher says. "We are still going to have accidents, but hopefully we are going to find that these accidents are not the result of the risk factors that we identify."