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GOGN3519 Iss 3 PDF
GOGN3519 Iss 3 PDF
GN
Published by:
RSSB
Block 2
Angel Square
1 Torrens Street
London
EC1V 1NY
© Copyright 2012
Rail Safety and Standards Board Limited
Uncontrolled When Printed
Document comes into force 02/03/2013
Supersedes GOGN3519 Iss 2 on 02/03/2013
Issue record
Issue Date Comments
One 04 October 2008 Original document
Two 04 September Contains new and reworded SPAD categories and
2010 some additional requirements for lead
organisations for investigations.
Three 01 December Contains revised definition of a SPAD and some
2012 additional requirements when reporting local
investigations.
Amended or additional parts of revised pages have been marked by a vertical black line
in the adjacent margin.
Superseded documents
The following Railway Group documents are superseded, either in whole or in part as
indicated:
Supply
The authoritative version of this document is available at www.rgsonline.co.uk.
Uncontrolled copies of this document can be obtained from Communications, RSSB,
Block 2, Angel Square, 1 Torrens Street, London EC1V 1NY, telephone 020 3142 5400
or e-mail enquirydesk@rssb.co.uk. Other Standards and associated documents can also
be viewed at www.rgsonline.co.uk.
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Contents
Section Description Page
Part 1 Introduction 4
G 1.1 Purpose of this document 4
G 1.2 Background 4
G 1.3 Principles 4
G 1.4 Related requirements in other documents 5
G 1.5 The structure of this document 5
G 1.6 Copyright 5
G 1.7 Approval and authorisation of this document 5
Appendices
Appendix A Decision criteria – formal investigations 28
Appendix B Decision criteria – local investigations 31
Appendix C Requirements for persons responsible for managing the investigation
process 33
Appendix D Requirements for persons appointed to lead an investigation 35
Appendix E Explanatory note on progress reporting requirements 39
Definitions 40
References 42
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Part 1 Introduction
G 1.1 Purpose of this document
G 1.1.1 GO/RT3119 Accident and Incident Investigation mandates requirements for the
investigation of accidents and incidents involving more than one infrastructure manager
or railway undertaking so that system improvements (including changes to European and
national standards, national operating rules and company systems and procedures)
necessary to prevent or reduce the likelihood of recurrence, or mitigate the
consequences, are identified and implemented.
G 1.1.2 The entitlements and role in the investigation process of railway industry parties and
others not directly involved in the event subject to investigation are defined.
G 1.1.3 This guidance document has been published by Rail Safety and Standards Board to give
guidance on interpreting the requirements of Railway Group Standard GO/RT3119. It
does not constitute a recommended method of meeting any set of mandatory
requirements.
G 1.2 Background
G 1.2.1 The requirements from GO/RT3119 reproduced in Part 2 of this document define a
procedural framework and common processes for the investigation of accidents and
incidents to enable:
c) Investigations to be completed and the findings made known in a timely way so that
lessons are learned (including the need to review risk controls) at the earliest
opportunity.
G 1.2.2 The requirements from GO/RT3119 reproduced in Part 2 of this document permit
infrastructure managers and railway undertakings to appoint a person independent of
either party involved to lead or participate in a formal investigation if required.
G 1.3 Principles
G 1.3.1 The requirements from GO/RT3119 as reproduced in this document are based on the
following principles:
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G 1.5.3 Specific responsibilities and compliance requirements are laid down in the Railway Group
Standard itself.
G 1.6 Copyright
G 1.6.1 Copyright in the Railway Group documents is owned by Rail Safety and Standards Board
Limited. All rights are hereby reserved. No Railway Group document (in whole or in part)
may be reproduced, stored in a retrieval system, or transmitted, in any form or means,
without the prior written permission of Rail Safety and Standards Board Limited, or as
expressly permitted by law.
G 1.6.2 RSSB members are granted copyright licence in accordance with the Constitution
Agreement relating to Rail Safety and Standards Board Limited.
G 1.6.3 In circumstances where Rail Safety and Standards Board Limited has granted a particular
person or organisation permission to copy extracts from Railway Group documents, Rail
Safety and Standards Board Limited accepts no responsibility for, nor any liability in
connection with, the use of such extracts, or any claims arising therefrom. This
disclaimer applies to all forms of media in which extracts from Railway Group Standards
may be reproduced.
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a) To establish the role that infrastructure and train borne systems might have played in
the events leading up to the incident. This might include such items as (according to
the incident concerned) SPAD incident history of a signal or group of signals,
operation of signals, management systems, braking distances, transitions between
signal types, staff supervision, training and working time patterns of those people
involved, vehicle systems and equipment etc.
b) To assess human factors issues, including, but not limited to, fitness for work, the
working environment, distraction issues, compliance with and fitness for purpose of
rules and procedures.
c) To examine the process for the input of data into equipment (including train data for
in-cab signalling systems).
e) To help determine how any lessons learnt from an incident might be communicated
to people.
f) To provide data for input to SMIS for analysis and use by all organisations that might
benefit from it.
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i) To analyse the impact on any supplementary risk, hazard studies or any other
relevant information.
G 2.1.2 Decision criteria for when to carry out a formal or local investigation
Extract from GO/RT3119 Accident and Incident Investigation
2.1 Responsibilities common to infrastructure managers and railway
undertakings
2.1.2 Decision criteria for when to carry out a formal or local investigation
2.1.2.1 Infrastructure managers and railway undertakings shall use the criteria in
Appendices A and B to identify when a formal or local investigation is required.
G 2.1.2.1 In applying the criteria listed in Appendices A and B, the following factors should also be
taken into consideration when deciding whether to instigate an investigation:
a) From situations where the lead organisation is unable to supply a competent person
to lead the investigation because of the company’s small size.
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c) Where involved parties jointly decide that the investigation would be best led by
someone independent of those parties to avoid perception of bias in the
investigation’s findings.
G 2.1.3.3 In addition, it may be helpful to invite independent technical experts to advise the
investigation panel on technical matters, depending on the circumstances of the accident
or incident and the collective expertise of the proposed panel or investigation team.
Independent technical expertise may be of value in:
d) Train operations.
e) Electrification.
f) Human factors.
G 2.1.3.4 Guidance as to the need for, and the names of, appropriate specialists may be obtained
from RSSB.
d) Witness statements.
j) Total Operations Process System (TOPS) train lists for the trains immediately
involved (or the equivalent for passenger trains).
k) Train running system on TOPS (TRUST) reports for the trains involved.
l) TOPS train consists for the last train(s) in each direction before the accident /
incident.
m) TRUST reports for the last train(s) in each direction before the accident or
incident.
n) Solid state interlocking or integrated electronic control centre (SSI / IECC) event
recorder data for a minimum of two hours prior to the accident / incident.
o) Telephone and radio recordings, where available, for the signal box and the relevant
traffic control room for the two hours immediately prior to the accident.
p) Train borne CCTV and visual recording media (interior and exterior).
G 2.1.5.2 Where a witness is called upon to provide oral evidence before an investigation panel,
the number of persons present at the time the evidence is given should be sufficient to
ensure that the hearing is properly conducted but does not inhibit the process of giving
evidence. The lead investigator should determine what that number should be and that
those present, collectively, have the necessary competence to evaluate the evidence.
G 2.1.5.3 When deciding the number of persons that should be present when oral evidence is
given, the following factors should be taken into consideration:
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a) Current and previous employment with any party involved in the accident / incident
and whether the activities performed in connection with such employment are likely
to be significant matters for the investigation in relation to the cause(s) of the event.
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G 2.2.2.2 The terms ‘earliest opportunity’ and ‘defined time limit’ referred to in 2.2.2.1 should be
discussed, ascertained and agreed between all affected parties and the designated lead
organisation. This should be done under the principle of cooperation, according to the
circumstances of the incident investigation concerned and also taking into account any
proposed extentions to time limits required. Time limits for reporting might also be
affected by legal issues or official requests from regulatory authorities. In all cases the
time limits referred to in the requirements should accord with the nature of the event
being investigated and be proportionate to the potential consequences, including those
that might have arisen had the circumstances been slightly different.
G 2.2.2.3 The final confirmation of an incident’s SPAD category (if there is one) may involve a
change to, or even deletion of, the provisional one that was allocated immediately
following the incident. The lead organisation should make this decision based upon their
investigation, evidence and professional expertise. In all such cases the lead
organisation’s final report should contain confirmation categories that accord with the
details of Appendix D (see also 2.2.4.4 and associated GN items).
c) Organisational changes.
G 2.2.4.4 The lead organisation should ensure that conclusions and recommendations are entered
into SMIS to comply with GE/RT8047 Reporting of Safety Related Information.
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G 2.2.4.7 In all cases the lead organisation should, if confirming or changing the SPAD category,
use the Table 2 List of confirmed category A SPAD event types. If the investigation
concludes that the circumstances do not comply with the conditions for one of the SPAD
categories stated in the Table, then they may consider re-designating the event (for
example, as an operating or possession irregularity, or an operating incident). Guidance
item G A.4.11 provides further guidance for lead organisations seeking to re-designate an
event as a result of their final investigation report.
a) Briefing signallers and train drivers about signals on routes over which they control
or operate that have been the subject of more than one SPAD incident during the
past five years.
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a) The remit has been achieved, or where this has not been possible, suitable action
has been taken.
c) The recommendations have been made in accordance with any requirements of this
standard.
G 2.2.5.2 If an SSC report has been completed as part of the investigation into a SPAD related
accident or incident, the SSC report should be included as an appendix to the formal
investigation report. It should be noted that a SSC may not always be held, which is why
the requirement states ‘if appropriate’.
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c) Organisational changes.
G 2.3.1.2 The term ‘defined time limit’ referred to in 2.3.1.1 should be discussed, ascertained and
agreed between all affected parties and the designated lead organisation under the
principle of cooperation, and according to the circumstances of the incident investigation
concerned. Time limits for reporting might also be affected by legal issues or official
requests from regulatory authorities. In all cases the time limits referred to in the
requirements should accord with the nature of the event being investigated and be
proportionate to the potential consequences, including those that might have arisen had
the circumstances been slightly different.
Or
G 2.3.2 Informing others of SPAD risk ranking and local investigation results
Extract from GO/RT3119 Accident and Incident Investigation
2.3 Responsibilities of the lead organisation for local investigations
2.3.2 Informing others of SPAD risk ranking and local investigation results
2.3.2.1 The lead organisation for a local investigation shall input the results of SPAD
risk ranking into SMIS.
G 2.3.2.1 No additional guidance provided.
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G 2.3.2.4 The lead organisation should ensure that conclusions and recommendations are entered
into SMIS to comply with GE/RT8047 Reporting of Safety Related Information.
G 2.3.2.6 If the original decision to identify the incident as a SPAD, and / or its given category is
subsequently changed as a result of the investigation, then the reports should clearly
indicate this outcome and apportionment of responsibility may be altered accordingly.
a) Briefing signallers and train drivers about signals on routes over which they control
or operate that have been the subject of more than one SPAD incident during the
past five years.
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G 2.4.2.3 A post-SPAD incident inspection should consider the following factors as appropriate
(non-exhaustive list):
a) Rail conditions.
c) Signal visibility and condition (including structure, head alignment, lens cleanliness
and red aspect filament and LED component condition, where applicable).
e) Vegetation encroachment.
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G 2.4.4 Criteria for deciding when a Signal Sighting Committee (SSC) is required
Extract from GO/RT3119 Accident and Incident Investigation
2.4 Responsibilities of infrastructure managers
2.4.4 Criteria for deciding when a Signal Sighting Committee (SSC) is required
GE/RT8037 Signal Positioning and Visibility sets out the requirements for the
sighting of signals and the composition of SSCs.
2.4.4.1 The infrastructure manager (Network Rail only) shall convene a SSC to assist
investigation of any alleged category A SPAD incident, with the following
specific exceptions:
a) One was convened following a previous category A SPAD incident at that
signal and all the following apply:
i) Its report is comprehensive and is available to the investigators.
ii) The investigators are satisfied that all the factors relevant to the latest
alleged category A SPAD incident were considered.
iii) The investigators are satisfied that no change has taken place to the
signal or at its location, which could affect those factors.
b) The signal had been commissioned within the previous 12 months.
c) The train was wrongly authorised to pass the signal at danger after coming
to a stand at the signal.
G 2.4.4.1 Signal Sighting Committees are normally only convened to investigate alleged category A
type SPAD incidents.
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G 2.4.5.2 Wherever it is possible for a driver to see the aspects of other signals, apart from those
immediately applicable to the train, then misreading error (because of cross-reading one
or more parallel signals, or reading-through to a signal ahead) is a possibility. In such
cases the committee should consider the likelihood of such an error occurring. The
scope of the investigation should therefore be expanded to take in such signals.
G 2.4.5.3 When agreeing an exact scope for the signal sighting investigation, the committee should
beware of applying a rigid formula; No two SPAD incidents are ever exactly the same. A
full examination of the SPAD incident signal itself should always be undertaken. Beyond
that, the scope of the exercise should take in all factors that could possibly have had a
bearing on the incident. The committee should always consider the possibility that the
conditions for an error to occur were set up before the first cautionary aspect came into
view. For example, it is possible that irregular spacing between green aspects, a change
between two, three, or four aspect signalling systems, or even the presence of a
significant landmark contributed to a SPAD incident at some distance ahead.
G 2.4.5.4 In certain cases, examination of the full aspect sequence may not be necessary.
However, this only applies in cases where it is safe to take the view that the signals (or
other infrastructure) in question could not possibly have contributed to the incident. In
areas of four-aspect signalling it may only be necessary to go back as far as the point at
which the single-yellow became visible, if any of the following scenarios apply:
a) The signal on the approach to the SPAD incident signal was subject to approach
release from red, and the train was being controlled correctly at that point.
b) The train was detained at a signal which then changed to single-yellow, and after the
train started away, a SPAD incident occurred at the next signal ahead.
c) The train had stopped in a properly controlled fashion for any reason (such as a
station stop) within the cautionary aspect sequence.
d) The SPAD incident occurred when the train started away against the red aspect,
having previously made a properly controlled stop.
G 2.4.5.5 In the course of the SSC investigation, a considerable amount of detailed information
should emerge. After the evidence has been collected, it should be a matter of routine to
consider whether or not the initial planned scope of the investigation was sufficient.
Sometimes during an investigation, the emerging facts indicate that the scope of the work
should be extended. For example, the potential for misreading error (due to cross-
reading or reading-through to other signals) may not be immediately obvious until a
detailed site examination is carried out.
G 2.4.5.6 The SSC also has a duty of care to consider potentially sub-standard conditions that lie
strictly outside the narrow confines of the incident itself. For example, where more than
one route leads to the SPAD incident signal, and the committee has doubts about its
approach view, then the view from all other directions should be checked. The adequacy
and effectiveness of all aspects and indications at the SPAD incident signal should
always be examined, even though it is only the red aspect that will have strict relevance
in the circumstances of the incident.
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a) The previous record of SPAD incidents at that signal and other signals in the vicinity.
d) The sighting of signals, lineside signs, indicators and other features preceding the
signal under investigation.
f) Aspect sequences on approach to and beyond the signal at which the SPAD incident
occurred.
g) Gradients.
i) Stopping position of trains (in regard to starting against red or yellow aspects at
platforms).
j) Train dispatch methodology (in regard to starting against red or yellow aspects at
platforms).
a) Visibility through windscreen (such as cleanliness and cracks, condition of sun visors
etc).
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G A.3.3 A generic remit may lead to an investigation that is neither proportionate to the potential
consequences of the accident or incident, nor to the risk associated with that specific
location. It is important to recognise that the remit should be suitably modified to focus the
attention of the investigation team on specific aspects of the accident or incident that
require to be examined; failure to do so may lead to an inadequate determination of
causes, risks, etc.
G A.3.4 Using a SPAD incident as an example, there are occasions when a train driver’s initial
reaction to his train having passed a signal at danger is an immediate oral admission that
he made an error. The significance of such an admission should not automatically be
allowed to lead to a narrowly defined remit that does not, for example, lead the
investigation team to consider an unmitigated SPAD trap that has resulted in several
SPAD incidents in recent years. Remits should therefore be written in a manner that
encourages the team to consider all relevant issues, including the caution signals on the
approach to the signal involved in the SPAD incident. This encouragement should lead
to the team retaining an open mind and a healthy scepticism when considering any early
preconceptions as to the causal model lying behind the SPAD incident in question.
G A.3.5 When developing the remit, the person responsible for the investigation process should
involve the other parties to the investigation so that collectively they agree the extent to
which similar accidents or incidents, past or related events involving the same equipment,
facilities, signals, personnel or rolling stock and changes to standards, management
systems and organisations should be specifically referenced within the remit. The person
responsible for the investigation process should discuss the remit with the person
appointed to lead the investigation to ensure that the remit and scope of the investigation
is understood and accepted. Additionally, the person appointed to lead the investigation
should ensure that all other team members similarly understand its scope.
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A1
When a SPAD has occurred and, according to available evidence,
a stop aspect, indication or end of in-cab signalled movement
authority was displayed or given correctly and in sufficient time for
the train to be stopped safely at it.
A2
When a SPAD has occurred and, according to available evidence,
the stop aspect, indication or end of in-cab signalled movement
authority concerned was not displayed or given correctly, but was
preceded by the correct aspects or indications.
Confirmed
A3
Category A
When a SPAD has occurred and, according to available evidence,
SPAD types verbal and/or visual permission to pass a signal at danger was
given by a handsignaller or other authorised person without the
authority of the signaller.
A4
When a SPAD has occurred and, according to available evidence,
a stop aspect, indication or end of in-cab signalled movement
authority was displayed or given correctly and in sufficient time for
the train to be stopped safely at it, but the train driver was unable
to stop his train owing to circumstances beyond his control (for
example, poor rail head adhesion, train braking equipment failure
or malfunction etc).
G A.4.3 Category A General Guidance on identification: Category A SPADs are split into four
distinct and numbered types that exactly match the detail contained in the provisional
categories stated in Table 1. There is no implied degree of importance or severity
between them. In all cases they specify events that have, or might have, led to a signal
being passed at danger without authority in the circumstances described. The distinct
numbering of Category A SPAD types is intended to enable more accurate analysis of
SPADs and help to better understand the circumstances of the incident. The categories
are not in themselves intended for the purposes of blame or liability.
G A.4.4 Category A1 Guidance: This category should be used to describe an event where the
signal passed at danger was displayed or indicated correctly, and with any correct
preceding indications (such as cautionary aspects and AWS warnings). In previous
versions of this RGS it was suggested that there may be occasions when a driver
voluntarily tells the signaller that he has passed a signal at danger, and that therefore this
is automatically described as a category A event. In this, as with the previous, version of
GO/RT3119 and its GN document, RSSB took the view that SPAD categorisations should
not be dependent on whether a driver has actually reported his train as having passed a
signal at danger. If such an occasion occurs it may, for example, be allocated a
provisional category A(p), with the knowledge that the incident will be investigated and
final confirmation of the category duly confirmed by the appropriate lead organisation.
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G A.4.6 Category A3 Guidance: A category A3 event is for situations where permissions have
apparently been given to a driver by a person who does not have the correct and proper
authority of the designated signaller for the signal or indication concerned. It should be
noted that, in full accordance with text in the Rule Book, a Person In Charge Of the
Possession (PICOP) and Engineering Supervisors (ES) are not handsignallers. Therefore
a situation where a driver passes a signal at danger in a possession without the PICOP
or ESs authority should be categorised as an A1 SPAD (and not an A3 SPAD). Similarly,
Level Crossing Attendants (LCA) should not to be construed as handsignallers, as they
cannot authorise drivers to pass signals at danger.
G A.4.7 The term ‘other authorised person’ stated in the A3 category might, for example, refer to
a designated pilotman. The Rule Book gives clear requirements for situations where
defined persons might or might not give permissions and authorities to drivers. The
categories shown in Tables 1 (provisional) and Table 2 (confirmed) of this RGS fully
support the activities described in the Rule Book.
G A.4.8 Category A4 Guidance: This category should be used to describe an event where the
signal passed at danger was correctly given or displayed, and where the preceding
indications were present and correct (such as cautionary aspects and AWS), but where
the driver was unable to stop his train in time owing to circumstances that were outside
his control. This might have been because of poor rail head adhesion, train braking
equipment failure or malfunctions etc. In all cases it should be where the driver will not
have had any reasonable way of preventing his train from passing the signal or indication
showing danger.
G A.4.9 Now that ROGS has redefined what is and what is not to be considered as a SPAD, the
old categories B, C and D have been removed from this version of GO/RT3119 and its
associated guidance. Incidents that occur involving any of the old SPAD category events
should continue to be investigated in their own right and according to the circumstances
concerned in each individual case. Guidance to the now discontinued SPAD categories of
B, C and D event has therefore been removed as it would no longer be required in
alignment to a SPAD event.
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G A.4.12 RGS users should note that there is no category stating an event where a signaller (or his
authorised agent thereof) gives incorrect authorisation to a driver to pass a signal at
danger. Such an event cannot be a SPAD as a train driver could have no logical basis for
questioning what, to him, should be a proper authorisation. If the lead organisation for the
investigation discovers that an incorrect authorisation was passed to the driver then that
event should be treated as an operating irregularity.
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Definitions
Accident
An unwanted or unintended sudden event or a specific chain of such events which have
harmful consequences; accidents are divided into the following categories: collisions,
derailments, level-crossing accidents, accidents to persons caused by rolling stock in
motion, fires and others.
Formal Investigation
A formally structured investigation of an accident or incident, led by an infrastructure
manager, railway undertaking or a person independent of all the parties involved in the
accident or incident, applying processes mandated in this document.
Immediate cause(s)
An unsafe act or unsafe condition which causes an accident or incident.
Incident
Any occurrence, other than accident or serious accident, associated with the operation of
trains and affecting the safety of operation.
Infrastructure manager
’'Infrastructure manager’ means a person who:
b) Manages and uses that infrastructure or station, or permits it to be used, for the
operation of a vehicle.
(Note: This definition is sourced from The Railways and Other Guided Transport Systems (Safety) Regulations
2006).
Investigation
A process conducted for the purpose of accident and incident prevention which includes
the gathering and analysis of information, the drawing of conclusions, including the
determination of causes and, when appropriate, the making of safety recommendations.
Lead organisation
The railway undertaking or infrastructure manager responsible for managing the processes
of local or formal investigations defined in this document and identified by applying criteria
defined in Appendix B of this document.
Local investigation
An investigation of an accident or incident, for which a formal investigation is not required,
by an infrastructure manager or a railway undertaking, using its defined company
procedures and requirements in respect of remit and results defined in this document.
Railway undertaking
A transport undertaking, as defined in the Railways and Other Guided Systems
Regulations 2006, whose safety certification covers operation of trains on the managed
infrastructure, as defined in the Railway Group Standards Code.
Safety authority
The national body entrusted with the tasks regarding railway safety in accordance with
Directive 2004/49/EC (the Railway Safety Directive). In Great Britain the safety authority is
the Office of Rail Regulation (ORR).
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SPAD
“Signal passed at danger” means any occasion when any part of a train proceeds beyond
its authorised movement to an unauthorised movement;
(b) the end of a safety related movement authority provided in an ATCS or train
protection system;
or
(d) stop boards (buffer stops are not included) or hand signals,
(e) vehicles without any traction unit attached or a train that is unattended run away
past a signal at danger;
or
(f) for any reason, the signal is not turned to danger in time to allow the driver to stop
the train before the signal.
Note: The above definition is taken from The Railways and Other Guided Transport
Systems (Safety) (Amendment) Regulations 2011.
Further information (together with associated forms) on the SPAD incident categorisation
and risk ranking system used in this document can be found on the RSSB website at
www.rssb.co.uk
Underlying cause(s)
Any factors which led to the immediate causes of accidents or incidents, or which resulted
in such causes not being identified and mitigated.
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References
The Catalogue of Railway Group Standards gives the current issue number and status of
documents published by RSSB. This information is also available from
www.rgsonline.co.uk.
RSSB documents
RT/3119/A Provisional SPAD Data Collection Form (Infrastructure
Managers)
RT/3119/B Provisional SPAD Data Collection Form (Railway
Undertakings)
RT/3119/C Provisional SPAD Data Collection Form (Infrastructure
Managers) for ERTMS
RT/3119/D Provisional SPAD Data Collection Form (Railway
Undertakings) for ERTMS
Other references
Directive 2004/49/EC Railway Safety Directive
The Railways and Other Guided Transport Systems
(Safety) Regulations 2006
The Railways and Other Guided Transport Systems
(Safety) (Amendment) Regulations 2011
The Railways (Accident Investigation and Reporting)
Regulations 2005
NIR3350 National Incident Report form ( www.railnotices.net)
GE/RT8000/M3 Managing incidents, floods and snow
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