10 Jul 2018 Bartholomew Patrick Coleman · Prevention of Future Deaths report Dorset
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Concerns raised 2 Easy public access to the railway track from the bridge View source Lack of warnings about the dangers of accessing the railway track View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Bartholomew Patrick Coleman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Bartholomew Patrick Coleman accessed a railway track near his home, lay on the track as a train approached, and died after being struck. Concerns included that the track was easily accessible from a bridge used by schoolchildren and that there appeared to be no warning about the dangers of accessing the area.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Easy public access to the railway track from the bridge
Wider context from the report “i. I understand children of school age cross the bridge to and from school. There is evidence to suggest that the area has been used by either groups or individuals to consume alcohol: there are discarded drinks containers in the area beyond the bridge and close to the train track. I am concerned that the railway track is easily accessible to members of the public from this bridge. In addition, there appears to be no warning as to the dangers presented by accessing this area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of warnings about the dangers of accessing the railway track
Wider context from the report “i. I understand children of school age cross the bridge to and from school. There is evidence to suggest that the area has been used by either groups or individuals to consume alcohol: there are discarded drinks containers in the area beyond the bridge and close to the train track. I am concerned that the railway track is easily accessible to members of the public from this bridge. In addition, there appears to be no warning as to the dangers presented by accessing this area .
” Open source report
19 Jun 2018 Andrew Thomas HANAHOE · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 4 Failure to resolve the safety of the foot crossing View source Inadequate trespass deterrence and fencing around the foot crossing View source Lack of repeater lights warning foot crossing users of approaching trains View source Inadequate physical separation between foot crossing users and the railway View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Andrew Thomas HANAHOE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Thomas HANAHOE died after walking onto Lindsells Foot Crossing at Biggleswade Railway Station as a train approached on 29 December 2017. Concerns were raised about the crossing’s safety, including its exposure to high-speed trains, inadequate fencing and the absence of measures such as repeater lights or trespass deterrence; the report states that the risk of a future death remained.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to resolve the safety of the foot crossing
Wider context from the report ““(1) The Post Incident Site Report states:
“Ideally this foot crossing should be closed. It crosses railway line that have trains regularly passing over it at speeds up to 125 mph.
“Biggleswade, like many towns, is growing in size and any future development in this area will bring housing closer to the crossing.
“Would the crossing be installed today?
“If the crossing is a recognised “foot path” then an enclosed foot bridge, to prevent items being thrown at or dropped on trains, should be installed, together with suitable fencing on both sides of the line adjacent to it, to prevent simple access to the tracks.
“Currently there is just “post and wire” fencing immediately next to the adjacent railway structure...
“If the crossing is to be retained, then “repeater lights” should be installed on either side of the crossing, so that users on the crossing can be made aware that a train is approaching”.
“Additionally trespass deterrence “Pyramid matting” that has been approved for use by Network Rail ... or similar should be installed on either side of the crossing, to deter simple access to the railway. Additional fencing is also needed between the existing line side fencing and the trespass deterrence to prevent access to the embankment.”
I understand that no decision has been made since this Report was made in January 2018, yet the risk of a future death remains.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Inadequate trespass deterrence and fencing around the foot crossing
Wider context from the report ““(1) The Post Incident Site Report states:
“Ideally this foot crossing should be closed. It crosses railway line that have trains regularly passing over it at speeds up to 125 mph.
“Biggleswade, like many towns, is growing in size and any future development in this area will bring housing closer to the crossing.
“Would the crossing be installed today?
“If the crossing is a recognised “foot path” then an enclosed foot bridge, to prevent items being thrown at or dropped on trains, should be installed, together with suitable fencing on both sides of the line adjacent to it, to prevent simple access to the tracks.
“Currently there is just “post and wire” fencing immediately next to the adjacent railway structure...
“If the crossing is to be retained, then “repeater lights” should be installed on either side of the crossing, so that users on the crossing can be made aware that a train is approaching”.
“Additionally trespass deterrence “Pyramid matting” that has been approved for use by Network Rail ... or similar should be installed on either side of the crossing, to deter simple access to the railway. Additional fencing is also needed between the existing line side fencing and the trespass deterrence to prevent access to the embankment.”
I understand that no decision has been made since this Report was made in January 2018, yet the risk of a future death remains.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of repeater lights warning foot crossing users of approaching trains
Wider context from the report ““(1) The Post Incident Site Report states:
“Ideally this foot crossing should be closed. It crosses railway line that have trains regularly passing over it at speeds up to 125 mph.
“Biggleswade, like many towns, is growing in size and any future development in this area will bring housing closer to the crossing.
“Would the crossing be installed today?
“If the crossing is a recognised “foot path” then an enclosed foot bridge, to prevent items being thrown at or dropped on trains, should be installed, together with suitable fencing on both sides of the line adjacent to it, to prevent simple access to the tracks.
“Currently there is just “post and wire” fencing immediately next to the adjacent railway structure...
“If the crossing is to be retained, then “repeater lights” should be installed on either side of the crossing, so that users on the crossing can be made aware that a train is approaching”.
“Additionally trespass deterrence “Pyramid matting” that has been approved for use by Network Rail ... or similar should be installed on either side of the crossing, to deter simple access to the railway. Additional fencing is also needed between the existing line side fencing and the trespass deterrence to prevent access to the embankment.”
I understand that no decision has been made since this Report was made in January 2018, yet the risk of a future death remains.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Inadequate physical separation between foot crossing users and the railway
Wider context from the report ““(1) The Post Incident Site Report states:
“Ideally this foot crossing should be closed. It crosses railway line that have trains regularly passing over it at speeds up to 125 mph.
“Biggleswade, like many towns, is growing in size and any future development in this area will bring housing closer to the crossing.
“Would the crossing be installed today?
“If the crossing is a recognised “foot path” then an enclosed foot bridge, to prevent items being thrown at or dropped on trains, should be installed, together with suitable fencing on both sides of the line adjacent to it, to prevent simple access to the tracks.
“Currently there is just “post and wire” fencing immediately next to the adjacent railway structure...
“If the crossing is to be retained, then “repeater lights” should be installed on either side of the crossing, so that users on the crossing can be made aware that a train is approaching”.
“Additionally trespass deterrence “Pyramid matting” that has been approved for use by Network Rail ... or similar should be installed on either side of the crossing, to deter simple access to the railway. Additional fencing is also needed between the existing line side fencing and the trespass deterrence to prevent access to the embankment.”
I understand that no decision has been made since this Report was made in January 2018, yet the risk of a future death remains.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with stakeholders to develop a closure proposal, secure funding and progress statutory closure arrangements for Lindsells Level Crossing.
Verbatim wording from the response “It is not within Network Rail’s power to simply close a level crossing that carries a public right of way and this requires liaison with stakeholders, including the relevant local authorities, to progress the necessary statutory process. Closing Lindsells Level Crossing would we believe require a large and very expensive ramped bridleway bridge to divert the existing rights of way.” Source location 2018-0184-Response-by-Network-Rail
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install audible alarms and larger-lensed miniature stop lights at Lindsells Level Crossing through the planned area-wide programme.
Verbatim wording from the response “While the option for closing the level crossing are being pursued, our risk assessment is reviewed regularly to identify if there are any additional mitigation measures that can be implemented to make the crossing safer.” Source location 2018-0184-Response-by-Network-Rail
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Additional repeater lights are not used because they could confuse users; existing near-side miniature stop lights provide sufficient warning time.
Verbatim wording from the response “The PISR suggests that “repeater lights” should be installed on either side of the crossing. It is not immediately clear what is meant by “repeater lights” but we assume this refers to lights facing into the crossing. This design has been considered many times before but after detailed risk assessment, we do not use such a design due to the risk of users becoming confused about whether it remains safe to cross if the light comes once they were on the crossing. Miniature stop lights are therefore installed at the near side of the railway facing towards oncoming users. The warning time gives sufficient time to safely cross to the other side.” Source location 2018-0184-Response-by-Network-Rail
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further boundary mitigation is not required because fencing is in good condition, fit for purpose, compliant, and unrelated to the incident’s access route.
Verbatim wording from the response “The fencing in the area of Lindsells Level Crossing is a mixture of Class 1 (1.8m high, which includes palisade fencing) and Class 3 (1.4m high), which includes post and wire boundary measures. The latest inspection recorded all fencing in the area of Lindsells Level Crossing to be in good condition, fit for purpose and compliant with the current fencing standard. We understand that there is no suggestion in this incident that access was taken to the railway as a result of failure of the boundary measures, therefore it is not considered that further boundary mitigation is required at this time.” Source location 2018-0184-Response-by-Network-Rail
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Anti-trespass matting is not considered appropriate because there is no evidence of shortcuts or trespass at the crossing.
Verbatim wording from the response “The PISR also suggests that anti-trespass matting should be installed on either side of the crossing. Trespass deterrent measures of this nature are considered and installed if, for example, there is evidence of people using the level crossing to trespass on the railway. There is no evidence of users taking shortcuts or other such behaviour at Lindsells Level Crossing. As a result, it is not considered that this type of deterrent is appropriate at this crossing.” Source location 2018-0184-Response-by-Network-Rail
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Closing a level crossing carrying a public right of way is outside the respondent’s power and requires a statutory process with stakeholders.
Verbatim wording from the response “It is not within Network Rail’s power to simply close a level crossing that carries a public right of way and this requires liaison with stakeholders, including the relevant local authorities, to progress the necessary statutory process. Closing Lindsells Level Crossing would we believe require a large and very expensive ramped bridleway bridge to divert the existing rights of way.” Source location 2018-0184-Response-by-Network-Rail
Open published response
30 Nov 2017 Sarah Athermith · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Lack of effective protection or warning at the level crossing View source Pedestrian confusion about the presence of a further train on the opposite track View source Obscured visibility of opposing trains for train drivers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sarah Athermith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 26 September 2017, Sarah Athermith was struck and fatally injured by a train while crossing the unprotected Wallows Lane railway crossing after stopping for another train. Concerns included the lack of a warning system for approaching trains, the risk of pedestrians becoming confused when trains pass in opposite directions, and the obstruction of drivers’ views by double-height freight carriages.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of effective protection or warning at the level crossing
Wider context from the report “1. Evidence emerged during the inquest that the Wallows Lane level crossing is an unprotected crossing and there is no method of warning of an approaching train .
2. There are whistle boards (train drivers should sound their whistles/horns on approach) in place to warn users. However, the crossing relies on users actively stopping, looking and listening for approaching trains before deciding if it is safe to cross .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Pedestrian confusion about the presence of a further train on the opposite track
Wider context from the report “3. There is a clear and present danger that pedestrians can become confused , as happened in this case when two trains pass each other at the same time and do not realise there is a further train on the opposite rail track .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Obscured visibility of opposing trains for train drivers
Wider context from the report “4. It also emerged that the freight train carriages were double height and obscured the opposite train drivers view .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain user safety instructions through stop, look and listen signage at Wallows Lane level crossing.
Verbatim wording from the response “In accordance with the risk assessment of the crossing, the protection measures at Wallows Lane level crossing rely on users actively stopping, looking and listening for approaching trains before deciding if it is safe to cross. These instructions are provided to crossing users via signs installed at the crossing.” Source location 2017-0350-Response-by-Network-Rail
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Risk-assess level crossings and periodically review risks, further mitigation and available technical solutions while crossings remain open.
Verbatim wording from the response “All level crossings on Network Rail’s infrastructure are risk assessed to determine the level of protection that is required to reduce the risk associated with that crossing so far as is reasonably practicable.” Source location 2017-0350-Response-by-Network-Rail
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress the statutory process for permanent closure of Wallows Lane level crossing with Walsall Local Authority.
Verbatim wording from the response “We confirm that Network Rail's preferred option is permanent closure of Wallows Lane level crossing. The crossing was closed to members of the public on 26 September 2017 via temporary order granted by Walsall Local Authority and remains closed today.” Source location 2017-0350-Response-by-Network-Rail
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use whistle boards requiring train drivers to sound horns to warn crossing users of approaching trains.
Verbatim wording from the response “Further protection has been installed at Wallows Lane level crossing in the form of whistle boards. Train drivers are required to sound their horn at the whistle boards to warn users of an approaching train. The sound of the horn is intended to be a further warning to any user who is actively assessing whether it is safe to cross.” Source location 2017-0350-Response-by-Network-Rail
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement physical safety enhancements including a marked decision point, solar lighting, vegetation clearance and highlighted gates and signage.
Verbatim wording from the response “As part of Network Rail’s continuous improvement to level crossing safety, in 2016 a number of enhancements were made at Wallow Lane level crossing to encourage safer user behaviours. These included:” Source location 2017-0350-Response-by-Network-Rail
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No known product can show passive-crossing users which line an approaching train is travelling on.
Verbatim wording from the response “Trains (passenger and freight) pass frequently at Wallows Lane, as they do at many level crossings. There is currently no known product that may be installed at passive level crossings to show users which line an approaching train is travelling on.” Source location 2017-0350-Response-by-Network-Rail
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Network Rail cannot itself permanently close a level crossing carrying a public right of way.
Verbatim wording from the response “It should be noted that, regrettably, it is not within Network Rail’s power to simply close a level crossing that carries a public right of way. Even when a clear safety case exists for closure of a crossing, Network Rail requires the relevant local authority to first support and then to progress the necessary statutory process.” Source location 2017-0350-Response-by-Network-Rail
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Permanent closure requires the relevant local authority to support and progress the statutory process.
Verbatim wording from the response “It should be noted that, regrettably, it is not within Network Rail’s power to simply close a level crossing that carries a public right of way. Even when a clear safety case exists for closure of a crossing, Network Rail requires the relevant local authority to first support and then to progress the necessary statutory process.” Source location 2017-0350-Response-by-Network-Rail
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Risk assessment concluded existing measures reduce risk at Wallows Lane level crossing so far as reasonably practicable.
Verbatim wording from the response “The risk assessment for Wallows Lane level crossing has considered if any existing technology may be used to warn of approaching trains at this location. Due to the close proximity of signals and junctions in both upside and downside directions, options to use technology are very limited and the evaluation concluded that risk at the crossing is reduced so far as is reasonably practicable.” Source location 2017-0350-Response-by-Network-Rail
Open published response
6 Nov 2017 Harminder DHILLON · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 3 Misuse of the level crossing exceeding reported levels View source Lack of CCTV monitoring of the level crossing View source Failure of the half barrier to deter road users from misusing the crossing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Harminder DHILLON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Harminder DHILLON drove around a lowered half barrier at Lidlington Level Crossing and collided with a train; the crossing was functioning appropriately. Concerns included the lack of CCTV monitoring, the limited deterrent effect of half barriers, and whether full-length barriers could prevent misuse and potential future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Misuse of the level crossing exceeding reported levels
Wider context from the report “(1) The level crossing is not monitored by CCTV and it is likely that the crossing is misused more than is reported
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of CCTV monitoring of the level crossing
Wider context from the report “(1) The level crossing is not monitored by CCTV and it is likely that the crossing is misused more than is reported
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure of the half barrier to deter road users from misusing the crossing
Wider context from the report “(2) The half barrier is not a deterrent to a road user who believes that their journey is being held up more than is necessary.
(3) A full length barrier, which is used on adjacent crossings on that line, would appear to be able to prevent misuse and prevent potential future deaths
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace Marston level crossing with a vehicular road bridge, eliminating the need for vehicles to traverse the crossing.
Verbatim wording from the response “Marston level crossing is scheduled to be replaced by a vehicular road bridge in 2019; this will eliminate the need for vehicles to traverse the crossing.” Source location Harminder-Dhillon-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop additional safety enhancements targeting accidental and deliberate misuse at automatic half-barrier crossings.
Verbatim wording from the response “Network Rail is constantly striving to improve passenger and level crossing user safety on our network. To this end Network Rail is currently, developing additional enhancements targeting accidental and deliberate misuse at AHBCs.” Source location Harminder-Dhillon-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Full barriers do not necessarily prevent deliberate misuse, so crossing design must be determined through local risk assessment.
Verbatim wording from the response “3. “A full barrier, which is used on adjacent barriers on the line, would appear to be able to prevent misuse and prevent potential future deaths.”” Source location Harminder-Dhillon-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Half barriers and associated warnings discourage deliberate misuse, although they cannot prevent it completely.
Verbatim wording from the response “2. “The half barrier is not a deterrent to a road user who believes that their journey is being held up more than is necessary”” Source location Harminder-Dhillon-Response
Open published response
20 Oct 2017 Scott RAYNER · Prevention of Future Deaths report Hertfordshire
View report summary
Concerns raised 1 Inadequate fencing beside the railway track View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Scott RAYNER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 16 April 2017, Scott Rayner trespassed onto the railway track near Watford Junction Station and was struck and killed by a train. The investigation identified inadequate fencing beside the track, particularly near a scrap metal dealer, creating a risk of adults and children trespassing onto a line where the speed limit was 100mph.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Inadequate fencing beside the railway track
Wider context from the report “British Transport Police investigating revealed that fencing beside the railway track was inadequate especially at the rear of a scrap metal dealer located off St Albans Road and Bedford Street, leading to a risk that adults and children may trespass on the line where the speed limit is 100mph.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a mandatory fencing standard requiring risk-assessed boundary management measures for Network Rail-controlled infrastructure.
Verbatim wording from the response “In accordance with its legal obligations, Network Rail implements a mandatory fencing standard “Management of Fencing and Other Boundary Measures” which applies to the boundary of Network Rail controlled infrastructure (the Fencing Standard).” Source location 2017-0345-Response-by-Network-Rail
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete enhancement work at identified Watford-area access locations, including installing additional palisade fencing around St Albans Road and Bedford Street.
Verbatim wording from the response “Although no faults were identified in the boundary fencing around St Albans Road and Bedford Street, the local operations team planned a further multi stakeholder inspection of the wider Watford area in order to investigate trespass incidents where specific locations of access were unknown. This took place on the 30 May 2017 in conjunction with the British Transport Police. A number of lineside locations in the Watford area were inspected and identified for additional enhancement work to prevent access to the railway. Work to implement this enhancement work was completed on 22 February 2018, which included installing additional palisade fencing in the St Albans Road and Bedford Street area.” Source location 2017-0345-Response-by-Network-Rail
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The boundary fencing was compliant and inspections identified no faults requiring repair in the St Albans Road and Bedford Street area.
Verbatim wording from the response “The last annual inspection of the St Albans Road and Bedford Street area, including the area to the rear of the H&D Motors, prior to April 2017 was undertaken on 26 June 2016. This inspection identified that there was no repair work required in the area and the boundary fencing was compliant with the Fencing Standard.” Source location 2017-0345-Response-by-Network-Rail
Open published response
Concerns raised 1 Unsafe track access from platforms View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Robert John MULLIS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Robert Mullis, who had Parkinsons, Vascular Dementia and was partially sighted, disembarked a train at Ashford railway station and walked onto the tracks, where he was struck by two trains and died from his injuries. The report raises a concern about track access from railway platforms, with Network Rail and South Eastern addressing this issue nationally.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Unsafe track access from platforms
Wider context from the report “I make this report with the knowledge that Network Rail and South Eastern are addressing the issue of track access from platforms nationally with Ashford being addressed in Autumn 2017
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install equivalent platform-end fencing and anti-trespass panels at the country end of platform 1 by the end of July 2017.
Verbatim wording from the response “I confirm that Network Rail is planning to install platform-end fencing and anti-trespass panels (commonly referred to as ‘witches’ hats) on platform 1, 2, 5 and 6 (the domestic platforms) at Ashford International Station and that these works are due to be completed by the 31st July 2017. More specifically, we have now installed platform-end fencing (in the form shown in Annex 1 below and witches’ hats in the form shown in Annex 2 at both ends of platforms 2, 5 and 6 and the London end of platform 1 at Ashford International Station. We will install equivalent fencing and witches’ hats at the country end of platform 1 by the end of July 2017.” Source location Robert-Mullis-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install platform-end fencing and anti-trespass panels at both ends of platforms 2, 5 and 6 and the London end of platform 1.
Verbatim wording from the response “I confirm that Network Rail is planning to install platform-end fencing and anti-trespass panels (commonly referred to as ‘witches’ hats) on platform 1, 2, 5 and 6 (the domestic platforms) at Ashford International Station and that these works are due to be completed by the 31st July 2017. More specifically, we have now installed platform-end fencing (in the form shown in Annex 1 below and witches’ hats in the form shown in Annex 2 at both ends of platforms 2, 5 and 6 and the London end of platform 1 at Ashford International Station. We will install equivalent fencing and witches’ hats at the country end of platform 1 by the end of July 2017.” Source location Robert-Mullis-Response
Open published response
13 Apr 2017 Daniel Campbell · Prevention of Future Deaths report North Northumberland
View report summary
Concerns raised 1 Failure to maintain fencing and walls separating the public footpath from the railway line View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Daniel Campbell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Campbell, aged 25, died instantly on 24 November 2015 after stepping into the path of a high-speed train between Spittal and Scremerston, Northumberland. The principal concern was that broken, missing or poorly maintained fencing and walls between a public footpath and the railway line created an easy opportunity for impulsive acts of suicide.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain fencing and walls separating the public footpath from the railway line
Wider context from the report “Disrepair of walls, fences or other barriers:-
Photographs of the location where the death occurred, provided by British Transport Police show that various sections of fencing and walls separating the public footpath from the railway line were broken, missing or in disrepair . While more substantial fencing is unlikely to prevent the trespass and death of a person who is determined to take his own life, insubstantial fencing or barriers create an easy opportunity for persons who might not otherwise act impulsively on fleeting suicidal thoughts after they have passed .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete an extensive lineside fencing upgrade north of the location between Spittal and Berwick.
Verbatim wording from the response “Network Rail has completed an extensive upgrade of our lineside fencing to the north of this location in conjunction with significant trespass and another suicide incident between Spittal and Berwick.” Source location 2017-0122-Response-by-National-Rail_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a site walk-through between Scremerston and Spittal to assess boundary robustness.
Verbatim wording from the response “In May, my team walked through the section between Scremerston and Spittal, whilst the fencing already meets Network Rail standards further works will be planned to improve the robustness of this boundary.” Source location 2017-0122-Response-by-National-Rail_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver planned fencing and boundary repairs in the incident section, restoring smaller stone-wall sections and replacing failed larger sections with lineside fencing.
Verbatim wording from the response “I can confirm that Network Rail has reviewed the active fencing proposals for upgrade on both sides of the track in the section where the incident occurred and have included these in our 2018 renewals plan. Stone walls are a specialist entity, which require specialist contractors. We will aim to repair/restore the smaller sections where possible, but large sections which have failed will be plugged with appropriate lineside fencing to maintain integrity.” Source location 2017-0122-Response-by-National-Rail_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review active fencing upgrade proposals for both sides of the incident section.
Verbatim wording from the response “I can confirm that Network Rail has reviewed the active fencing proposals for upgrade on both sides of the track in the section where the incident occurred and have included these in our 2018 renewals plan. Stone walls are a specialist entity, which require specialist contractors. We will aim to repair/restore the smaller sections where possible, but large sections which have failed will be plugged with appropriate lineside fencing to maintain integrity.” Source location 2017-0122-Response-by-National-Rail_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Plan further works to improve boundary robustness between Scremerston and Spittal.
Verbatim wording from the response “In May, my team walked through the section between Scremerston and Spittal, whilst the fencing already meets Network Rail standards further works will be planned to improve the robustness of this boundary.” Source location 2017-0122-Response-by-National-Rail_Redacted
Open published response
23 Aug 2016 Stephen Sean CAHILL · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 2 Failure to undertake a review of fencing and access gates at the location View source Inadequate deterrence and hindrance provided by railway access gates and fencing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephen Sean CAHILL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Sean CAHILL died after being struck by a train while lying across the track near Sandy Railway Station on 29 March 2016. The principal concern was that the access gate and fencing provided little deterrence or hindrance to people seeking to access the railway line, and a recommended review had not been undertaken.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a review of fencing and access gates at the location
Wider context from the report “(1) The British Transport investigation revealed that the deceased gained access to the railway line through an access gate. Both the gate and fence provide little deterrence or hindrance to someone wanting to gain access to the railway.
(2) The Investigation recommended a review of the fencing and access gates be undertaken at the location as it is relatively easy to access the track from both sides of the line. It is understood that this has not been undertaken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Inadequate deterrence and hindrance provided by railway access gates and fencing
Wider context from the report “(1) The British Transport investigation revealed that the deceased gained access to the railway line through an access gate. Both the gate and fence provide little deterrence or hindrance to someone wanting to gain access to the railway.
(2) The Investigation recommended a review of the fencing and access gates be undertaken at the location as it is relatively easy to access the track from both sides of the line . It is understood that this has not been undertaken.
” Open source report
4 Aug 2016 Susan Elizabeth HAMLETT · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1 Inadequate physical barriers at the railway access gate View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Susan Elizabeth HAMLETT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 8 March 2016, Susan Elizabeth HAMLETT walked onto a railway line and lay across the tracks, where she was killed instantly by a train. The investigation identified that an access gate provided little deterrence to railway access and that a more substantial fence had not been installed.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Inadequate physical barriers at the railway access gate
Wider context from the report “(1) The British Transport investigation revealed that the deceased gained access to the railway line through an access gate at Lower Farm Road, Bromham, Bedfordshire. The gate is of wooden construction and provides little deterrence or hindrance to someone wanting to gain access to the railway. The gate has a wooden fence around it of a similar height.
(2) The investigation identified that the area around the wooded track access gate, at the western side of the bridge, should be removed and replaced with a more significant fence as a matter of urgency . It is understood that this has not been undertaken .
” Open source report
24 Jun 2016 Richard Hinchliffe · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure to identify prolonged presence on a station platform View source Failure to flag concerning presence on a station platform View source Lack of regular checks of barriers onto rail lines to ensure appropriate security View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Richard Hinchliffe · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Hinchliffe died on 2 October 2015 after accessing railway tracks between Blackfriars and London Bridge stations and suffering fatal electrocution. Concerns were raised about how securely the barrier to the railway lines was maintained and whether the presence of a person apparently asleep on the platform would have been identified as a safety or security concern.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to identify prolonged presence on a station platform
Wider context from the report “(2) Mr Hinchliffe was seemingly asleep on the platform for approximately one hour before gaining access onto the line. The evidence was that Blackfriars station is staffed 24 hours. It is not clear whether his presence would have been noted and flagged as a possible security/safety concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to flag concerning presence on a station platform
Wider context from the report “(2) Mr Hinchliffe was seemingly asleep on the platform for approximately one hour before gaining access onto the line. The evidence was that Blackfriars station is staffed 24 hours. It is not clear whether his presence would have been noted and flagged as a possible security/safety concern .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of regular checks of barriers onto rail lines to ensure appropriate security
Wider context from the report “(1) The evidence at the inquest was that the barrier gate from platform 1 onto the rail lines was clearly marked with warning signs and “witches hat” matting. ████████ evidence was that normal practice is also to secure the barriers with a cable tie to deter unauthorised access but to allow reasonable emergency access when required. However, the evidence suggested that at the time of the PFS visit the gate was tied shut using a shoe lace. This visit was several days after the incident and is not necessarily indicative of the situation on 2 October. However, the evidence at the inquest also suggested that Mr Hinchliffe gained access through the barrier with some ease which might suggest that the barrier was not secured. It is not clear how often the barriers onto the lines are checked to ensure appropriate security is in place.
” Open source report
26 Feb 2016 Jakovas Fofonovas · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Failure to restrict public access to the railway View source Failure to create a safer environment at the bridge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jakovas Fofonovas · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jakovas Fofonovas died on 23 May 2015 after accessing the railway and being struck by a train near Abbey Wood railway station. Concerns were raised that unsafe bridge features enabled access to the railway and that recommendations to improve safety and restrict public access had not been implemented by the inquest.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict public access to the railway
Wider context from the report “Recommendations in The BTP Post Fatality Report to create a safer environment at the bridge and restrict public access to the railway had not been effected by the time of the inquest . The court did not have the benefit of Network Rail spokesperson in court to provide evidence of future plans
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to create a safer environment at the bridge
Wider context from the report “Recommendations in The BTP Post Fatality Report to create a safer environment at the bridge and restrict public access to the railway had not been effected by the time of the inquest . The court did not have the benefit of Network Rail spokesperson in court to provide evidence of future plans
” Open source report
17 Jul 2015 Adam Lee Connelly · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Inadequate restriction of public access to the railway track from the steps accessing footbridge 57 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Adam Lee Connelly · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Adam Lee Connelly was found deceased beside railway tracks near footbridge 57 between Walkden and Atherton after sustaining injuries consistent with being struck by a train. The principal concern was that the approximately five-foot walls of the steps leading to the footbridge could allow a person of reasonable athletic ability to access the railway track, creating a risk of future fatalities.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Inadequate restriction of public access to the railway track from the steps accessing footbridge 57
Wider context from the report “i. Due to the height of the walls of the steps which are used to access footbridge 57 on the railway line between Walkden and Atherton train stations, a person of reasonable athletic ability could gain access to the railway track , which could lead to future fatalities at this location on the railway
” Open source report
27 May 2015 Mathew Lee Hoare · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1 Failure of after-hours station and track access barriers to prevent access View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mathew Lee Hoare · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mathew Lee Hoare was found on a live rail near Wandsworth Road Train Station after entering Clapham High Street Station and accessing its platforms and tracks after hours. He sustained fatal injuries after being electrocuted and struck by an oncoming train; concerns related to ineffective security equipment and the ease of access through widely spaced yellow tape.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure of after-hours station and track access barriers to prevent access
Wider context from the report “(1) The lack of effective security equipment preventing access to the station and tracks after the hours of operation.
(2) The ease at which Mr Hoare was able to access the station and tracks by climbing through widely spaced yellow tape.
” Open source report
23 Mar 2015 Elliott Bignall · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 2 Poor lighting at the foot crossing View source Inadequate warning signage at the foot crossing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Elliott Bignall · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Elliott Bignall, aged 17, died from multiple injuries after being hit by a train at Langsmead Foot Crossing in Ferring, West Sussex, on 9 September 2014; the death was recorded as accidental. Concerns included poor lighting and inadequate warning signage at the crossing, and the risk that people using headphones or phones might not hear or see an approaching high-speed train.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Poor lighting at the foot crossing
Wider context from the report “Sergeant ████████ the investigating officer from BTP gave evidence to the Inquest and described the foot crossing at Langmeads as horrendous. He said the location of the foot crossing was poorly lit and there was inadequate signage at the site warning pedestrians of the dangers associated with the crossings.
My concerns are that individuals wearing headphones or on the phone, who are unaware of the dangers associated with the crossing, may not hear or see the high speed train approaching. This could lead to further fatalities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Inadequate warning signage at the foot crossing
Wider context from the report “Sergeant ████████ the investigating officer from BTP gave evidence to the Inquest and described the foot crossing at Langmeads as horrendous. He said the location of the foot crossing was poorly lit and there was inadequate signage at the site warning pedestrians of the dangers associated with the crossings .
My concerns are that individuals wearing headphones or on the phone, who are unaware of the dangers associated with the crossing, may not hear or see the high speed train approaching. This could lead to further fatalities.
” Open source report
13 Nov 2014 John Robert Wright · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Failure to balance hearing protection with the ability to hear oncoming trains View source Failure to brief crews on potential train routes in areas with multiple lines View source Failure to brief and enforce safe methods of work View source Failure to maintain trackside maintenance crews’ vigilance around live railway lines View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Robert Wright · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Robert Wright, a Network Rail track maintenance worker, was struck by an oncoming train while working at Newark Northgate station on 22 January 2014 and died from his injuries on 31 January 2014. The concerns identified were the need for frequent reminders and training about vigilance, clearer briefings on train routes and safe working methods, and a balance between hearing protection and the ability to hear approaching trains.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to balance hearing protection with the ability to hear oncoming trains
Wider context from the report “Despite its obviousness I am concerned that track side maintenance crew need frequent reminders/training as to the need to maintain vigilance at all times when working in the vicinity of lines along which trains can pass.
When working in the vicinity of stations and/or points on the network where there are multiple lines, crews should be fully briefed as to the potential route of trains through stations or across any such lines, including, where reasonably practicable, consulting timetables; and safe methods of work are briefed and enforced.
Further, I am concerned that there needs to be a balance struck between the ensuring that track side maintenance crews are provided with personal protective equipment such as hearing protection and an ability to hear oncoming locomotives/trains .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to brief crews on potential train routes in areas with multiple lines
Wider context from the report “Despite its obviousness I am concerned that track side maintenance crew need frequent reminders/training as to the need to maintain vigilance at all times when working in the vicinity of lines along which trains can pass.
When working in the vicinity of stations and/or points on the network where there are multiple lines, crews should be fully briefed as to the potential route of trains through stations or across any such lines, including, where reasonably practicable, consulting timetables ; and safe methods of work are briefed and enforced.
Further, I am concerned that there needs to be a balance struck between the ensuring that track side maintenance crews are provided with personal protective equipment such as hearing protection and an ability to hear oncoming locomotives/trains.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to brief and enforce safe methods of work
Wider context from the report “Despite its obviousness I am concerned that track side maintenance crew need frequent reminders/training as to the need to maintain vigilance at all times when working in the vicinity of lines along which trains can pass.
When working in the vicinity of stations and/or points on the network where there are multiple lines, crews should be fully briefed as to the potential route of trains through stations or across any such lines, including, where reasonably practicable, consulting timetables; and safe methods of work are briefed and enforced .
Further, I am concerned that there needs to be a balance struck between the ensuring that track side maintenance crews are provided with personal protective equipment such as hearing protection and an ability to hear oncoming locomotives/trains.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain trackside maintenance crews’ vigilance around live railway lines
Wider context from the report “Despite its obviousness I am concerned that track side maintenance crew need frequent reminders/training as to the need to maintain vigilance at all times when working in the vicinity of lines along which trains can pass .
When working in the vicinity of stations and/or points on the network where there are multiple lines, crews should be fully briefed as to the potential route of trains through stations or across any such lines, including, where reasonably practicable, consulting timetables; and safe methods of work are briefed and enforced.
Further, I am concerned that there needs to be a balance struck between the ensuring that track side maintenance crews are provided with personal protective equipment such as hearing protection and an ability to hear oncoming locomotives/trains.
” Open source report
19 Sep 2014 Aaron Jacob Plowman · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1 Failure to block access to commercial-unit roofs under the railway arches View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Aaron Jacob Plowman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 14 March 2014, Aaron Jacob Plowman was found to have fallen through a damaged plastic roof over garage premises onto a concrete floor. The principal concerns were that access to the roofs of commercial units under the railway arches had not been blocked and that a specific access point from nearby shops remained viable.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to block access to commercial-unit roofs under the railway arches
Wider context from the report “(1) Access to the roofs of the commercial units under the railway arches has not been blocked off from persons gaining access by climbing up from the street.
(2) Specifically the access point from the Lycamobile kiosk and Sonny Kebab and Chicken shop on the New Kent Road under the railway arches remains viable .
” Open source report
18 Sep 2014 William Dennis FRANCE · Prevention of Future Deaths report West Somerset
View report summary
Concerns raised 2 Telephone located beyond the pedestrian stop line at the level crossing View source Obstructed visibility for motor vehicle drivers approaching the crossing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
William Dennis FRANCE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Dennis France died on 21 March 2013 when his car was struck by a high-speed train while he attempted to cross Athelney Railway Crossing with the automatic half barriers down. The barriers had remained down for an unusually prolonged period due to an earlier engineering train movement and signalling issues. Concerns included obstructed visibility for motor vehicle drivers approaching the crossing and the position of the crossing telephone beyond the pedestrian stop line.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Telephone located beyond the pedestrian stop line at the level crossing
Wider context from the report “(2) Although not a factor in the death the telephone at the level crossing was some 8 metres beyond the pedestrian stop line .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Obstructed visibility for motor vehicle drivers approaching the crossing
Wider context from the report “(1) Motor vehicle drivers approaching the crossing from either side have to go up a rise and their visibility towards Taunton is obstructed in part by the barrier controls and the road crossing which is also at an angle .
” Open source report
8 Jul 2014 Anthony Shane Ponting · Prevention of Future Deaths report Somerset (West)
View report summary
Concerns raised 3 Failure to position S.H.1 boards 3 metres from the line View source Tripping hazards on the crossing surface View source Reduced sighting time caused by trackside vegetation at the S.H.1 sign View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony Shane Ponting · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony Shane Ponting, a 34-year-old man, was killed on 11 July 2013 while using an authorised pedestrian crossing over the Bristol to Taunton railway line near Highbridge, Somerset. The inquest jury returned an accidental verdict. A report identified potential risks to other crossing users, including reduced sighting time from vegetation, incorrectly positioned S.H.1 boards, and tripping hazards on the crossing surface.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to position S.H.1 boards 3 metres from the line
Wider context from the report “(ii) the S.H.1 boards should have been positioned 3 metres from the line .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Tripping hazards on the crossing surface
Wider context from the report “(iii) Tripping hazards on the crossing surface
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Reduced sighting time caused by trackside vegetation at the S.H.1 sign
Wider context from the report “(i) reduced sighting time caused by track side vegetation growth for pedestrians crossing from the downside for both up and down trains and on the upside for down trains at the S.H.1 sign
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cut back vegetation and maintain six-monthly inspections to preserve pedestrian sightlines.
Verbatim wording from the response “The vegetation growth was cut back during the first week of August 2013. In terms of managing the vegetation going forward, this has been and will continue to be routinely checked at six-monthly inspections. Most recently, those inspections were conducted on 16th” Source location 2014-0322-Response-by-Network-Rail
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Renew the crossing surface with rubber panels free of tripping hazards and check its condition during six-monthly inspections.
Verbatim wording from the response “Concern 5(iii) has been addressed. In early March 2014 and as part of more extensive track works in the area, the surface system was completely renewed in modern rubber panels free of tripping hazards. Again the surface is checked for condition at each six-monthly inspection regime, the next one being in the first week of December 2014.” Source location 2014-0322-Response-by-Network-Rail
Open published response
7 May 2014 Emma Isabel Lifsey · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Delays in replacing old-style level-crossing lights with LED lights View source Delays in researching the effect of glare on signal visibility View source Lack of adequately bright wig wag lights at level crossings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Emma Isabel Lifsey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Emma Lifsey, a four-year-old passenger in a car, died after the car entered the path of a train at Beech Hill level crossing on 4 December 2012. The concerns included glare affecting the visibility of the crossing lights, the poor brightness of old-style filament bulbs, and the time being taken to replace them with LED lights and research the effects of glare.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Delays in replacing old-style level-crossing lights with LED lights
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Delays in researching the effect of glare on signal visibility
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of adequately bright wig wag lights at level crossings
Wider context from the report “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.
” Open source report
Concerns raised 4 Lack of safeguards preventing recurrence of the crossing accident View source Failure of the pedestrian warning light system to remain synchronised with multiple approaching trains View source Positioning of the pedestrian warning light before the gate, preventing visibility after gate passage View source Crossing design unsuited to a very busy commuter and freight line View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Malcolm James Ernest Potter · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Malcolm James Ernest Potter, aged 76, was struck and killed by a northbound train while crossing the Dernford railway crossing on 3 October 2013, after a southbound train had passed. The concerns identified were that the pedestrian warning light was positioned before the gate and was not synchronised to account for another approaching train, creating a risk that pedestrians would cross after the light appeared to turn green without seeing a renewed red signal. The crossing was considered unsuitable for the busy railway line, and the report noted that the accident could recur.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of safeguards preventing recurrence of the crossing accident
Wider context from the report “(4) While there have been no previous accidents there is nothing to prevent this accident reoccurring at any time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure of the pedestrian warning light system to remain synchronised with multiple approaching trains
Wider context from the report “(1) The warning light for pedestrians is positioned before the gate through which the pedestrian passes before crossing the track. A red light is triggered by a train coming towards the crossing and turns green once it passes. The warning light system relates to individual trains and is not synchronised to take account of another train about to arrive. It is therefore possible for a pedestrian to see a red light turn green, and pass through the gate to cross the track oblivious to the light having turned red again due to an approaching train.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Positioning of the pedestrian warning light before the gate, preventing visibility after gate passage
Wider context from the report “(2) It is the view of British Transport Police that this death could have been prevented by positioning the light on the opposite side of the track . Pedestrians would then see that another train was coming even after they have passed through the gate. A horn or some similar noise was recommended as an additional safeguard as provided on other crossings.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Crossing design unsuited to a very busy commuter and freight line
Wider context from the report “(3) The type of crossing is more suited to a quiet rural line than a very busy commuter and freight line as this one is , running between London and Cambridge.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations