The relevant elements from the RAIB Report
298 Since 1989 the crossing has been subject to frequent misuse. It has become commonplace for crossing users to cross the line whilst the red light is showing and the yodel is sounding. This is evidenced by an analysis of the 11 occurrence books that were obtained following the accident on 3 December 2005. These covered the period from 10 April 1999 to 6 December 2005. The data relating to this period is summarised as follows:
There were a total of 303 recorded instances of misuse.
Of the above;
- 140 involved adult males;
and
The remainder involved a mixed group or the gender was not identified in the record.
More than 90% of instances that were recorded in the occurrence books involved persons who started to cross after the lights had switched to red.
299 Some crossing keepers were far more likely to record misuse than others. It can therefore be deduced that the occurrence books are an incomplete record of the level of crossing misuse at Elsenham.
300 One crossing keeper has reported that on four occasions in the two years prior to the accident he was subjected to verbal abuse when he attempted to point out the dangers of misusing the crossing.
301 The investigation has revealed that there was no systematic management process to monitor and review the levels of misuse at Elsenham level crossing. In particular there was no process to ensure that relevant entries in the occurrence book were entered into the railway industrys Safety Management Information System (SMIS). Nevertheless, the Network Rail territory, Anglia, had been aware of the level of misuse at Elsenham and had identified it as a crossing for review. No timescale was established for this review to be completed.
391 The risk assessment carried out at Elsenham by Network Rail in April 2005 was incorrect and was not the subject of consultation with the station operator. The resulting assessment of the risks posed to users at Elsenham was therefore substantially flawed (paragraph 348, Recommendation 3).
392 According to the analysis preformed by the RAIB as part of this investigation, the inherent risk factors at Elsenham are amongst the highest at any station pedestrian crossing on the UK mainline network, and therefore deserving of special attention (paragraph 358).
393 Network Rails own assessment of risk 14 using its semi-quantative scoring system shows Elsenham to have the third highest risk at any station pedestrian crossing on the UK network.