B318 Network Rail Shared Learning NRL24-02

Incorrect Installation of ESR Equipment

Issued to: Network Rail line managers, safety professionals and accredited contractors
Ref: NRL24-02
Date of issue: 02/04/2024
Location: Multiple sites
Contact: Gary Smith, Senior Engineer

Overview

There were several serious and concerning incidents during 2023, involving Emergency Speed Restrictions
(ESRs) and Temporary Speed Restrictions (TSRs). Although the causal factors for each incident were slightly
different, the common element was a failure to fully install and implement the speed restriction. These have
led to unsafe situations with trains overspeed across the defect and the subsequent response caused
unnecessary disruption to railway operations and our passengers. These incidents have also resulted in the
maintenance teams accessing the infrastructure to inspect the positioning of the signage.

Incident One

Overview: North, West & Central – 19th June 2023
This incident was where an implemented ESR did not have a magnet installed. This led to the train being
withdrawn from service for an inspection, disrupting service and causing a safety hazard to the railway
operation.

Key points
This was an installation issue.
The Team leader did not submit a photograph to their Section Manager or equivalent, quoting the location
details of the ESR applied
Due to human error when reinstating back to the original TSR, the Permanent Way team forgot to reinstall the
AWS magnet.

Incident Two

Overview: East Coast South – 11th June 2023

This incident happened where a 20 mph ESR was erected due to hot weather precautions. There was an
existing 20mph ESR in place on the Down Slow 2 line, with associated warning equipment already installed on the Down Fast from where it could be accessed.
With a lack of competent staff locally to undertake ESR designs, a Section Manager from a different area
designed the Down Fast 20mph ESR, which did not consider other speed restrictions in the area owing to a lack
of local knowledge. Staff were unable to install equipment on site as per the design.
It was realised post implementation of the speed on the 11th of June, that the order of the warning equipment
was incorrect as staff had added the warning equipment for the Down Fast 20mph ESR beyond the pre
existing warning equipment for the Down Slow 2 (with directional arrow) 20mph ESR.

Key points

The ESR was designed by someone from a different area and did not consider other speed restrictions in the
area owing to a lack of local knowledge.

The local Permanent Way team had insufficient competent staff to create or amend an ESR design.
The issue of the warning equipment for both ESRs being the incorrect sequence, was not reported nor escalated
to Incident Control.

This incident has highlighted the challenge of compliantly providing warning equipment for speed restrictions
in complex areas and alternative solutions are being explored.

 

File name : Shared-Learning-NRL24-02-Incorrect-Installation-of-ESR-Equipment.pdf

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B318 NWR Shared Learning NRL24-02

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