Source · Prevention of Future Deaths

Richard Hill

Date: 15 Nov 2018 Coroner: Stephanie Haskey Area: Nottinghamshire Responses identified: 1 / 1 View PDF

The railway crossing lacked essential telephones and Network Rail contact information, posing a risk of repeat incidents due to inadequate emergency communication at the site.

Date 15 Nov 2018
56-day deadline 10 Jan 2019 est.
Responses identified 1 of 1
Railway related deaths

Coroner's concerns

AI summary
The railway crossing lacked essential telephones and Network Rail contact information, posing a risk of repeat incidents due to inadequate emergency communication at the site.
View full coroner's concerns
That 'the British Transport Police post incident site report; by Paul Hardy; a copy of which has been sent to you; states the following: 1.1 There are no telephones at the crossing: 1.2 No contact telephone for Network Rail is displayed at the crossing 1.3 There is a possibility of a repeat incident at or near to this location in the future and that Network Rail staff should be made aware of this_

Responses

1 respondent
Richard Hill
15 Nov 2018 PDF
Disputed

• Network Rail stated that Cromwell Lane level crossing is a public highway crossing with manned barriers. • Network Rail confirmed the crossing is CCTV monitored at Carlton signal-box by a local signaller. • Network Rail noted that a narrative risk assessment for the crossing was last carried out on 20 December 2017, identifying appropriate mitigation measures. (AI summary)

View full response
Dear Madam, Regulation 28: Report to Prevent Future Deaths - Richard John Hill I refer to your report dated 15th November 2018 made under paragraph 7, schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. On behalf of all at Network Rail, I would like to take this opportunity to express my sincere condolences to the family of Mr Hill. As noted in your report, Mr Hill died on 17th August 2018 when he was struck by a London North Eastern train near to Cromwell Lane Level Crossing. I detail below Network Rail's considered response to the matters of concern raised in your report. Cromwell Lane Level Crossing Cromwell Lane level crossing is a public highway crossing with manned barriers. The crossing is CCTV monitored at Carlton signal-box by the local signaller who's responsibility is to ensure that the crossing is clear by use of the CCTV equipment before allowing a train to approach the crossing. The crossing is located on Norwell Lane which is the link between Cromwell and Norwell villages. Network Rail Infrastructure Limited Registered Office: Network Rail, One Eversholt Street, London, NW1 2DN Registered in England and Wales No. 2904587 www.networkrail.co.uk

[Page 2] Cromwell Lane level crossing narrative risk assessment (NRA) was last carried out on 201h December 2017. The NRA identifies appropriate mitigation measures to manage the risk associated with the crossing so far as is reasonably practicable. The NRA identifies the following risk controls in place at Cromwell Lane level crossing:
• Full barriers with barrier lamps - the barriers prevent anyone gaining access to the railway when trains are approaching. Lamps on top of barriers are there for visibility to approaching road traffic.
• CCTV cameras - as noted above CCTV cameras allow the signaller to check that the crossing is clear of vehicles and pedestrians before allowing an approaching train to proceed into the crossing area. The CCTV monitor will automatically switch off once he presses the "crossing clear'' button. The CCTV system is purely to check the crossing is clear when a train is approaching and is not monitored or recorded 24 hours.
• Road instructional signage - to forewarn users that they are approaching a level crossing.
• Interlocked barriers - this is a safety system preventing trains approaching unless barriers are in down position.
• Signaller (Located at Carlton signal box) - this is the person who looks after the crossings within his section of responsibility.
• Electrification warning signage - signage to highlight height restrictions due to OHLE (Overhead Line Equipment) above the railway carrying 25,000 volts.
• LED road lights - these lights are brighter and more visible than normal road lighting to mitigate against low sun.
• Cyclical maintenance and inspections - these are carried out every three months to ensure the asset is compliant to all relevant standards. Any defects found during the inspection are referred to the focal maintenance delivery unit for their attention to be rectified within the specified timescales.
• Regular risk reviews and assessments - these are carried out based on risk identified through ALCRM (All Level Crossing Risk Model). Any misuse or changes to the crossing triggers a review of the crossing.

[Page 3] Additional mitigation at Cromwell Lane level crossing We have also considered the findings you reference were identified within the Post Incident Site Report (the "PISR"). The PISR is a site assessment undertaken by the British Transport Police ("BTP") immediately after an incident. While it provides valuable information the PISR is not undertaken by specialists with detailed level crossing knowledge so the actions are not always practicable. There is no requirement for a telephone Cromwell Lane level crossing because it is a CCTV monitored crossing. Should a member of the public be concerned about an emergency situation, this should be reported by calling 999. Network Rail also maintains a 24 hour emergency number (03457 11 41 41) for the reporting of safety incidents on or near the railway, details of which are widely publicised. The emergency services closely liaise with Network Rail to pass information to signallers where required. Anti-trespass & anti-suicide measures In October of 2018 Network Rail implemented a team of patrollers who cover this level crossing and other at-risk locations in the area. They patrol on a risked based priority all locations which are identified by the rail industry's suicide and trespass workstreams. Moreover, Network Rail has funded an Embedded BTP Inspector to coordinate our activity across the rail industry and bring in BTP data. We have funded overtime patrols deployed on a priority basis and have established a joint operation to prevent suicide and trespass, working with local stakeholders to focus on areas including Cromwell Lane level crossing. I hope this response answers your concerns but if I can be of further assistance, or if you would like further clarification, please do not hesitate to contact me. Route Managing Director LNE&EM Network Rail

Report sections

Investigation and inquest
An Inquest into the death of Richard John Hill was held on 14th November 2018
Circumstances of the death
Mr Hill died on 17th August 2018 when he was struck by a London North Eastern train near to the Cromwell Lane level crossing; also known as the Norwell Lane level crossing, near Newark, Nottinghamshire NG23 6JQ_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action:

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Report details

Date of report
15 November 2018
Coroner
Stephanie Haskey
Coroner area
Nottinghamshire

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Jan 2019 (estimated).

Sent to

Network Rail

Part of a series

2 reports
2023-0102Deceased All responses identified

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