The RAIB have released their report into the derailment of a DLR unit at West India Quay station on 10th March 2009. The train derailed because it travelled through incorrectly set points.
The incident happened at 1002 when the 0950 DLR service from Bank to Lewisham, formed of units 86 and 30, travelled through a set of points at North Quay Junction, just north of West India Quay station. The train was being driven by the “passenger service agent” at the time as a result of a signalling failure between Westferry and West India Quay. No injuries were reported with either the 80 passengers or the passenger service agent.
The immediate cause of the derailment was that the train travelled through the points in a trailing direction when they were not correctly set for this movement.
Casual and possible factors were:
* the passenger service agent did not identify that the points were set reverse,
and stop the train
* the passenger service agent did not see the unlit point position indicator and
stop the train at the indicator
* the control centre controller did not intervene to stop the movement of the train
* the control centre controller did not follow the emergency shunt procedure and reserve 1125 points in the correct (normal) position
* the control centre controller was not aware of the exact position of train LEW109 because he had the block occupancy switched off on his overview
* the ‘red bar’ lamp in 1125B point position indicator was unlit
As a result of the investigation a number of recommendations have been made to Docklands Light Railway Ltd, covering the following areas:
* criteria for the location of point position indicators and the review of their
sighting and subsequent improvements
* alarm management systems in the system management centre (SMC)
* the replacement of all point position indicators with ones that are more
conspicuous when lit
* adequate control of changes to the design and operations of the railway
Three recommendations (plus two made as a result of a previous investigation to a derailment at Deptford Bridge on 4th April 2008) have also been made to Serco Docklands, covering the following areas:
* the reporting by staff of unlit point position indicators
* monitoring certain staff to assess levels of compliance
* training related to operations in emergency shunt mode
* operational safety management systems
* identifying safety process indicators
* The full report can be viewed here (PDF).
Source: RAIB