Rail Accident Report
Freight train derailment at London Gateway,
Essex
24 December 2021
Report 14/2023
                                     December 2023
This investigation was carried out in accordance with:
• the Railway Safety Directive 2004/49/EC
• the Railways and Transport Safety Act 2003
• the Railways (Accident Investigation and Reporting) Regulations 2005.
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This report is published by the Rail Accident Investigation Branch, Department for Transport.
Preface
Preface
The purpose of a Rail Accident Investigation Branch (RAIB) investigation is to
improve railway safety by preventing future railway accidents or by mitigating their
consequences. It is not the purpose of such an investigation to establish blame or
liability. Accordingly, it is inappropriate that RAIB reports should be used to assign
fault or blame, or determine liability, since neither the investigation nor the reporting
process has been undertaken for that purpose.
RAIB’s findings are based on its own evaluation of the evidence that was available at
the time of the investigation and are intended to explain what happened, and why, in a
fair and unbiased manner.
Where RAIB has described a factor as being linked to cause and the term is
unqualified, this means that RAIB has satisfied itself that the evidence supports both
the presence of the factor and its direct relevance to the causation of the accident or
incident that is being investigated. However, where RAIB is less confident about the
existence of a factor, or its role in the causation of the accident or incident, RAIB will
qualify its findings by use of words such as ‘probable’ or ‘possible’, as appropriate.
Where there is more than one potential explanation RAIB may describe one factor as
being ‘more’ or ‘less’ likely than the other.
In some cases factors are described as ‘underlying’. Such factors are also relevant
to the causation of the accident or incident but are associated with the underlying
management arrangements or organisational issues (such as working culture).
Where necessary, words such as ‘probable’ or ‘possible’ can also be used to qualify
‘underlying factor’.
Use of the word ‘probable’ means that, although it is considered highly likely that the
factor applied, some small element of uncertainty remains. Use of the word ‘possible’
means that, although there is some evidence that supports this factor, there remains a
more significant degree of uncertainty.
An ‘observation’ is a safety issue discovered as part of the investigation that is not
considered to be causal or underlying to the accident or incident being investigated,
but does deserve scrutiny because of a perceived potential for safety learning.
The above terms are intended to assist readers’ interpretation of the report, and to
provide suitable explanations where uncertainty remains. The report should therefore
be interpreted as the view of RAIB, expressed with the sole purpose of improving
railway safety.
Any information about casualties is based on figures provided to RAIB from various
sources. Considerations of personal privacy may mean that not all of the actual effects
of the event are recorded in the report. RAIB recognises that sudden unexpected
events can have both short- and long-term consequences for the physical and/ or
mental health of people who were involved, both directly and indirectly, in what
happened.
RAIB’s investigation (including its scope, methods, conclusions and recommendations)
is independent of any inquest or fatal accident inquiry, and all other investigations,
including those carried out by the safety authority, police or railway industry.
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Freight train derailment at London Gateway,
Essex, 24 December 2021
Contents
Preface3
Summary7
Introduction9
    Definitions                                                                   9
The accident10
    Summary of the accident                                                      10
    Context11
The sequence of events17
Background information19
Analysis34
    Identification of the immediate cause                                        34
    Identification of causal factors                                             37
    Identification of underlying factors                                         47
    Data uncertainties and assumptions                                           52
    Previous occurrences of a similar character                                  53
Summary of conclusions 55
    Immediate cause                                                              55
    Causal factors                                                               55
    Underlying factors                                                           56
Actions reported as already taken or in progress relevant to this report 57
Recommendations and learning point58
    Recommendations58
    Learning point                                                               60
Appendices61
    Appendix A – Glossary of abbreviations and acronyms                          61
    Appendix B – Derivation of traction and brake torques                        62
    Appendix C – Simulation of longitudinal train dynamics                       64
    Appendix D – Wagon derailment simulations                                    69
    Appendix E – Urgent operating notice concerning trains with Ecofret 2 wagons 71
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Summary
Summary
At around 05:45 hrs on 24 December 2021, 5 wagons of a 33-wagon intermodal
freight train derailed at low speed as the train was entering the rail terminal at London
Gateway port, Essex. The derailment started when wheels on a wagon in the middle
part of the train suddenly lifted off the track, just before reaching the port boundary,
with the other wagons becoming derailed as they passed over points within the rail
terminal. While no one was injured, infrastructure damage disrupted rail freight access
into and out of the port for 14 days.
The first derailed wagon was the unloaded centre wagon of a triple-wagon, which was
made up of three individual wagons permanently coupled together. The wagons on
the train either side of the unloaded centre wagon were all loaded, and a train brake
application had recently been made when the derailment occurred. A longitudinal train
dynamic simulation model, specially developed as part of the investigation, showed
that compressive forces generated in the train were larger towards the middle of the
train, where the triple-wagon was located, and rapidly increased to a maximum as
the centre wagon approached the place where it became derailed. Data from the
train’s on-train data recorder showed that this was shortly after brake forces acting
on the locomotive had peaked and that the train’s brakes would have been starting to
release.
Derailments in 2015 involving an earlier version of the type of triple-wagon involved
demonstrated that triple-wagons of this design configuration were susceptible to
derailment when large longitudinal compressive forces are suddenly applied. Early
derailment simulation studies had confirmed this and helped inform a decision to
lengthen the bar coupler on the earlier version of these wagons to improve derailment
resistance. The wagon designers identified the need to make other design changes
when the new version of the triple-wagon was developed for unrelated reasons.
However, although the risks due to longitudinal compressive force continued to be
recognised, the need to make further design improvements to address them was
not deemed to be necessary. Derailment simulations undertaken in support of the
investigation helped show that the new version of the triple-wagon remained similarly
susceptible to derailment and confirmed that the lack of payload on the centre wagon,
and possibly in-service degradation of the bogie, increased the derailment risk.
The investigation found that the risks associated with the longitudinal dynamic
behaviour of long freight trains are not well understood in the rail industry and that
there are limited processes, tools, and knowledge resources available to assess
and manage them. This was identified as an underlying factor. The investigation
has identified the design management arrangements that were adopted during the
development of the new version of the triple-wagon as another underlying factor. It
is possible that these arrangements limited the designers’ ability to understand the
dynamic behaviour of the triple-wagon and did not result in the identification of critical
performance requirements.
Report 14/2023                               7                                December 2023
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          RAIB has made three recommendations. One is directed to VTG Rail, the owner
Summary
and developer of the triple-wagon, covering the need to identify and implement any
          necessary design changes and operating restrictions. The second is directed to GB
          Railfreight, the operator of the train, covering the need to develop instructions and
          best practice guidance for its operations staff. The third is directed to RSSB covering
          the need to raise the rail industry’s understanding of the derailment risks associated
          with longitudinal compressive forces and the management strategies that need to be
          introduced.
Report 14/2023                              8                               December 2023
          London Gateway
Introduction
Introduction
Definitions
1   Metric units are used in this report, except when it is normal railway practice to
    give speeds and locations in imperial units. Where appropriate the equivalent
    metric value is also given.
2   All mileages are taken from a datum at London Fenchurch Street station. Left and
    right orientations relate to the direction of travel of the train when the accident
    occurred.
3   The term ‘rail industry’ refers to the various organisations and parties, each with
    individual responsibilities and duties, that co-operate to deliver rail services on the
    mainline railway in Great Britain.
4   The term ‘wagon’ refers to an item of freight rolling stock that is braked but
    unpowered. A freight train comprises a number of wagons that are coupled
    together and hauled by a locomotive. The term ‘triple-wagon’ refers to three
    wagons that are permanently coupled together, while ‘twin-wagon’ refers to
    two permanently coupled wagons. The term ‘single wagon’ is used to refer to a
    wagon that is not permanently coupled to another wagon. The term ‘vehicle’ is
    used to refer to an item of rolling stock in general, in this case either a wagon or a
    locomotive.
5   The term ‘coupler’ refers to any arrangement of equipment designed to connect
    two vehicles, thereby controlling the degree to which they can separate or draw
    closer together.
6   The report refers to ‘Ecofret 1’ and ‘Ecofret 2’ wagons. These are variants of the
    FWA type of intermodal wagon (see paragraphs 47 to 58).
7   The report contains abbreviations. These are explained in appendix A.
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               The accident
The accident
Summary of the accident
               8    At around 05:45 hrs on 24 December 2021, five wagons within freight train
                    reporting number 4L471 derailed on the Thames Haven line on the approach to
                    London Gateway port, near to Stanford-le-Hope, Essex (figure 1). Train 4L47
                    was the scheduled GB Railfreight (GBRf) 22:35 hrs (on 23 December) intermodal
                    service from the freight terminal at Hams Hall, near Birmingham, to London
                    Gateway port. The service was carrying freight containers.
               9    Train 4L47 had been routed off the Down Tilbury line at Thames Haven Junction.
                    The train had just started to enter the port infrastructure when the derailment
                    occurred. The 12th wagon derailed to the left on a section of line without points or
                    crossings (termed as ‘plain line’) approaching LG11 signal, just before reaching
                    the boundary between Network Rail’s infrastructure and that managed by the port
                    operator (figure 2). The locomotive’s on-train data recorder (OTDR) registered
                    that the train brakes were being applied at the time of the derailment and that the
                    train was rapidly slowing to a speed of 9 mph (14.5 km/h). The 11th, 13th, 14th and
                    15th wagons subsequently derailed as a consequence.
               10 Realising something was wrong, the driver brought the train to a stand on the
                  Port Arrivals line, 740 metres beyond LG11 signal. The train remained coupled
                  together during the derailment, with all the wagons staying upright. Figure 3
                  shows the position of the train after the derailment.
Location of accident
© Crown Copyright. All rights reserved. Department for Transport 100039241. RAIB 2023
Figure 1: Extract from Ordnance Survey map showing the location of the accident at London Gateway.
1
                An alphanumeric code, known as the ‘train reporting number’, is allocated to every train operating on Network
               Rail infrastructure.
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               London Gateway
                                                                                                                                                                                         The accident
                           To Pitsea and                                                                                              Not to scale
                           Shoeburyness
                                                                                                                                      Some lines omitted for clarity
                           Stanford-le-Hope                                                                              Infrastructure boundary
                           station                                                                                  Network Rail        DP World
                                                                                                               The Bridleway
                                                      Path of train 4L47                                                                      Camera and
                                                                                                               level crossing
                                                                                                                                                scanning
                                                      Extent of derailment                                                                                          To rail
                                                                                                                                               equipment
                                                                                                Point of derailment                                               terminal
                                                                 Down
                                                                                                                             LG11                                  sidings
                                                                      T  hames
                                                                               Haven
                                                                                       line
                                                                  Up Th
                                                                        ames H                                                       LG1    LG2            Thames Haven Single
                                                                                                                                                                                  line
                                                                              aven lin
                                                                                       e                                                                            Port Arrivals line
                                                                                                                                                                Port Departures line
LG3
                            Thames Haven
                            Junction                                                                                                                   London
                                                                                                                                                     Gateway Port
         ne
Summit
              li
Initial
                   line
         bury
y
    n Til
ilbur
peak
 Dow
Up T
To
                                                               1 in 328
                            1 in 374
1 in 141
1 in 181
1 in 108
London
                                                                                                                             LG11
Figure 2: Track layout on Thames Haven line showing the gradient profile and the route of the train.
11 No one was injured in the accident, although there was major damage caused
   to the railway infrastructure and six wagons required repair. The derailment also
   resulted in major disruption to rail freight access into the port.
Context
Location
12 London Gateway port is a deepwater container terminal on the Thames, located
   around 40 km east of central London. Constructed on the site of a former oil
   refinery, it opened for operation in 2013. The Thames Haven line connects the
   mainline railway to the rail terminal at the port. The line and associated railway
   infrastructure were redesigned and renewed as part of the construction work for
   the new port. The new rail terminal is capable of handling trains up to 775 metres
   long.
Report 14/2023                                                                                           11                                              December 2023
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The accident
Down Thames Haven line
Wagon 13
Wagon 12 (hidden)
Wagon 11
Direction
                                      of travel
Port
                                                       Arrivals
                                                         line
                                       Port
                                                                     Thames Haven
                                    Departures
                                                                       Single line
                                       line
Figure 3: Position of the train after the derailment (image courtesy of British Transport Police).
13 Trains join the Thames Haven line at Thames Haven Junction (26 miles
                  41 chains) on the London, Tilbury, and Southend line. It initially comprises two
                  lines: the Down Thames Haven, used by trains entering the port, and the Up
                  Thames Haven, used by departing trains. Trains entering the port pass LG11
                  signal, then a user worked level crossing (The Bridleway) (28 miles 7 chains) and,
                  shortly afterwards, the infrastructure boundary (28 miles 9 chains) between the
                  mainline railway and the port. The two lines then join to form the Thames Haven
                  Single line at LG1 points. The single line continues under the overbridge carrying
                  the port access road, after which LG2 and LG3 points provide access to the Port
                  Arrivals and Port Departures lines and the rail terminal sidings (figure 2).
Report 14/2023                                       12                                      December 2023
               London Gateway
14 Trains routed towards London Gateway port enter the Down Thames Haven line
The accident
   on a right-hand curve and climbing gradient. After reaching an initial peak, the
   curvature on the line eases to the left and the railway continues to climb, reaching
   a final summit at 27 miles 45 chains, just over one mile (1.7 km) beyond the
   junction. The line then descends on a gradient of 1 in 108 and becomes level
   shortly before LG11 signal. The gradient profile is shown at figure 2.
15 Various maximum permitted line speeds apply for trains routed into the port rail
   terminal. These are:
        • a 25 mph (40 km/h) limit from Thames Haven Junction on the Down Thames
          Haven line to 28 miles 33 chains on the Thames Haven Single line, shortly after
          the overbridge
        • a 15 mph (24 km/h) limit from 28 miles 33 chains to 29 miles 74 chains on the
          Thames Haven Single line, and also on the Port Arrivals and Port Departures
          lines
        • a 5 mph (8 km/h) limit beyond 29 mile 74 chains on the Thames Haven Single
          line.
16 Train movements outside the port rail terminal are controlled by lineside signals
   operated from Network Rail’s Upminster signalling control centre. LG11 signal
   controls access into the rail terminal. LG11 signal, and the signals used to control
   movements within the rail terminal, are operated from the London Gateway rail
   control centre.
Organisations involved
17 Network Rail owns, manages, and maintains the railway infrastructure on the
   approach to the infrastructure boundary where the 12th wagon (wagon 122)
   derailed. This section of line lies within Network Rail’s Anglia route, which is part
   of its Eastern region.
18 DP World owns, manages, and maintains the railway infrastructure within London
   Gateway port (beyond the infrastructure boundary) where the four other wagons
   (wagons 11, 13, 14 and 15) consequently derailed and train 4L47 came to a
   stand.
19 GBRf operated train 4L47 and employed its driver. It leased wagon 12, an FWA
   type wagon, and the 11 other FWA type wagons on the train. It also either leased
   or owned the other vehicles on the train, including the locomotive, and was
   responsible for the maintenance for most of them. DP World contracted GBRf to
   operate the port rail terminal and to provide the ground staff required.
20 VTG Rail owned and maintained the FWA wagons on the train, including
   wagon 12, and leased them to GBRf. All the FWA wagons on the train were of
   the Ecofret 2 variant, a wagon of recent design. VTG Rail specified the Ecofret 2
   design requirements and led the development, procurement and approval work
   needed to obtain authorisation for placing the wagons into service. VTG Rail
   appointed consultants to assist it with the work.
2
    Wagons are referred to in the report by their position along the train.
Report 14/2023                                               13               December 2023
London Gateway
               21 Wabtec UK Ltd3 (referred to as ‘Wabtec’ in the remainder of this report) designed,
The accident
manufactured, and supplied the bogies that VTG Rail required be fitted to the
                  Ecofret 2 wagons. It supported VTG Rail with the approval work needed to obtain
                  authorisation for placing Ecofret 2 wagons into service.
               22 WH Davis designed and manufactured the Ecofret 2 wagon underframe. It was
                  based on the design of the Ecofret 1 wagon, an earlier FWA wagon variant, the
                  design rights for which VTG Rail already owned. WH Davis also assembled
                  the wagons and supported VTG Rail with the approval work needed to obtain
                  authorisation for placing Ecofret 2 wagons into service.
               23 VTG Rail appointed AEGIS Certification Services Limited (ACS) to undertake
                  conformity assessments for the Ecofret 2 wagon against applicable technical
                  standards and safety requirements. This was part of the approval work needed to
                  obtain authorisation for placing Ecofret 2 wagons into service.
               24 The Rail Safety and Standards Board (RSSB) is the organisation that supports
                  the rail industry in improving its safety performance. Its principal activities include:
                  managing research and development programmes; developing, agreeing and
                  maintaining standards; and providing insight, analysis and guidance on railway
                  systems, safety and health.
               25 Network Rail, DP World, GBRf, VTG Rail, Wabtec, WH Davis, ACS and RSSB
                  freely co-operated with the investigation.
               Train involved
               26 Train 4L47 was formed of a class 66 diesel-electric locomotive and a mixture of
                  33 intermodal flat wagons. These were:
                       • four Ecofret 2 triple-wagons, each comprising three wagons permanently
                         coupled with a bar coupler between each wagon (12 wagons altogether)
                       • six FEA type twin-wagons (a mixture of FEA-A, FEA-B and FEA-C types), each
                         comprising a pair of wagons permanently coupled with a bar coupler between
                         them (12 wagons altogether)
                       • nine FEA-S type single wagons.
                       Each triple-wagon, twin-wagon, single wagon and the locomotive were coupled to
                       each other using a conventional screw coupling and side buffer arrangement.
               27 Wagon 12, the first wagon to derail, was the centre wagon of an Ecofret 2
                  triple- wagon. As such, it was permanently coupled (by a bar coupler) to two outer
                  wagons. These were wagon 11 in front, and wagon 13 behind. Except for wagon
                  12, all the wagons on the train carried at least one freight container. Table 1 is
                  a summary of the consist of train 4L47 and the payload recorded on the train
                  document. The train had an approximate length of 621 metres.
3
                   Previously known as Wabtec Rail Ltd.
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                                                                               Connection to
The accident
Vehicle      Type             Number         Payload4                                        Outcome
                                                                               next vehicle
Locomotive Class 66      66779      -                                          SC+B
Wagon 1    FEA-C         650026     Two containers (29.3t + 30.0t)             BC
Wagon 2    FEA-C         650025     Two containers (29.7t + 19.4t)             SC+B
Wagon 3    FEA-S         640632     Two containers (31.9t + 29.8t)             SC+B
Wagon 4    FWA-Ecofret 2 7045202301 One container (20.7t)                      BC
Wagon 5    FWA-Ecofret 2 7045210510 Two containers (30.1t + 26.6t)             BC
Wagon 6    FWA-Ecofret 2 7045202319 One container (12.0t)                      SC+B
Wagon 7    FEA-A         630037     Two containers (16.0t + 29.8t)             BC
Wagon 8    FEA-A         630038     Two containers (13.8t + 27.2t)             SC+B
Wagon 9    FEA-S         640666     Two containers (4.4t + 29.3t)              SC+B
Wagon 10 FEA-S           640909     Two containers (27.4t + 29.7t)             SC+B
Wagon 11 FWA-Ecofret 2 7045202574 One container (18.9t)                        BC            Derailed later
Wagon 12 FWA-Ecofret 2 7045210643 No container                                 BC            First to derail
Wagon 13 FWA-Ecofret 2 7045202566 One container (20.0t)                        SC+B          Derailed later
Wagon 14 FEA-B           643020     Two containers (29.3t + 10.0t)             BC            Derailed later
Wagon 15 FEA-B           643019     One container (29.9t)                      SC+B          Derailed later
Wagon 16 FWA-Ecofret 2 7045202335 One container (29.4t)                        BC
Wagon 17 FWA-Ecofret 2 7045210528 One container (28.4t)                        BC
Wagon 18 FWA-Ecofret 2 7045202327 One container (29.4t)                        SC+B
Wagon 19 FEA-A           630019     One container (14.2t)                      BC
Wagon 20 FEA-A           630020     Two containers (43.4t + 28.4t)             SC+B
Wagon 21 FEA-S           640915     Two containers (18.6t + 25.6t)             SC+B
Wagon 22 FEA-C           650032     Two containers (29.4t + 30.4t)             BC
Wagon 23 FEA-C           650031     One container (30.4t)                      SC+B
Wagon 24 FEA-S           640686     Two containers (28.4t + 29.3t)             SC+B
Wagon 25 FEA-S           640660     Two containers (17.9t + 29.8t)             SC+B
Wagon 26 FEA-B           640621     Two containers (27.8t + 13.8t)             BC
Wagon 27 FEA-B           640622     Two containers (29.2t + 29.3t)             SC+B
Wagon 28 FEA-S           640642     Two containers (29.3t + 29.2t)             SC+B
Wagon 29 FWA-Ecofret 2 7045202111 One container (4.4t)                         BC
Wagon 30 FWA-Ecofret 2 7045210411 Two containers (29.0t + 29.8t)               BC
Wagon 31 FWA-Ecofret 2 7045202103 One container (11.0t)                        SC+B
Wagon 32 FEA-S           640662     Two containers (26.4t + 28.0t              SC+B
Wagon 33 FEA-S           640691     Two containers (29.3t + 30.2t)             -
SC+B Screw coupling plus side buffers
BC   Bar coupler
Wagon type:
Single wagon
Twin-wagon
Triple-wagon
Table 1: Train 4L47 consist and recorded payload. 4
4
 Payload in tonnes (t). Containers on the derailed wagons were examined and weighed after the derailment. The
measurements suggested that the actual train payload may have differed from that recorded on the train document.
RAIB has taken account of this in the supporting wagon derailment simulation work (appendix D).
Report 14/2023                                        15                                        December 2023
London Gateway
               Railway and port infrastructure
The accident
28 The track on the Thames Haven line was laid for the port’s opening in 2013. It
                  comprises CEN60 rail5 supported on concrete sleepers and stone ballast. The
                  rails are seated on polymer pads and secured to the sleepers with steel rail
                  fastenings.
               29 Network Rail’s track geometry measurement train ran over the Down Thames
                  Haven line on 13 July 2021. This was the last recording run before the derailment.
                  No track geometry faults were recorded in the vicinity of the derailment that
                  required intervention6 before train 4L47 ran over the line on 24 December 2021.
                  RAIB compared data from the recording run with track gauge and cross level
                  measurements that Network Rail made immediately after the derailment. This
                  indicated that the track had not significantly deteriorated in the meantime.
               30 On entry to the port rail terminal, trains pass a set of lineside cameras and optical
                  character recognition (OCR) scanners. These collect information about the train
                  and the container payload (figure 4). The equipment is located just after the port
                  access road overbridge (figure 2). It includes lights to illuminate the train as it
                  passes.
Figure 4: Camera and scanning equipment on
                                                entry to the port (diagram courtesy of DP World).
Staff involved
               31 The driver of train 4L47 joined GBRf in January 2019 with no prior experience as
                  a train driver. They were assessed as competent to operate class 66 locomotives
                  in October 2019 and assessed as competent to operate trains over the route into
                  London Gateway port in January 2021. They had regularly driven trains into and
                  out of the port since then. The driver had no previous safety incidents recorded by
                  GBRf.
               External circumstances
               32 The nearby weather station in Corringham (2.5 km to the north-east) recorded an
                  air temperature of 7.7°C at the time of the derailment and a wind speed of 1 km/h.
                  There was no report of precipitation. It was dark when the derailment occurred.
5
                   A type of flat-bottom rail having a weight of 60 kilograms per metre.
               6
                   According to Network Rail company standard NR/L2/TRK/001 ‘Inspection and maintenance of permanent way’.
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               London Gateway
The sequence of events
The sequence of events
Events preceding the accident
33 Train 4L47 departed from Hams Hall on time at 22:35 hrs on 23 December 2021.
   The train was routed via Whitacre Junction, Rugby and Watford Junction and
   arrived at Wembley European Freight Operating Centre (EFOC) at 00:52 hrs on
   24 December where there was a change of drivers.
34 After preparing the locomotive and checking the handbrakes on the train were
   released, the driver who operated train 4L47 from Wembley EFOC to London
   Gateway port was ready to depart. GBRf drivers needed to know if the train
   included Ecofret 2 wagons because this required them to apply the brake in a
   specific manner (see paragraph 138a). GBRf stated that drivers would know if
   there were Ecofret 2 wagons as this was detailed on the train document. The
   driver who operated train 4L47 to London Gateway, however, stated that they
   used the running brake test7 (required to take place at the start of the journey) to
   determine if there were Ecofret 2 wagons, since it was their experience that trains
   containing this type of wagon responded differently during these tests.
35 The train departed from Wembley EFOC at around 03:45 hrs, three minutes early.
   It was routed along the North London line to Stratford and then onto the London
   Tilbury and Southend line at Barking. The driver recalled that the train felt “heavy”,
   and that the journey had been slow because of an unusually large number of
   restrictive signals, but that nothing untoward occurred during this part of it. Train
   4L47 passed over Thames Haven Junction and onto the Down Thames Haven
   line at 05:22 hrs, six minutes later than scheduled.
Events during the accident
36 Figure 5 is an analysis of the locomotive OTDR recording of the journey along the
   Down Thames Haven line, starting at Thames Haven Junction. It shows:
      • the throttle number (between 1 and 8) that was selected by the driver to control
        traction effort
      • the train brake pipe pressure (which is measured at the locomotive) and the
        corresponding locomotive brake cylinder pressure generated in response to
        braking changes made by the driver
      • the gradient profile (track elevation)
      • the train’s speed and the maximum permitted line speed at the location
      • the location of important infrastructure features and of train 4L47 at the time of
        the derailment, including the position of wagon 12 (leading bogie).
7
 Running brake tests are required to test the effectiveness of the train’s brakes in accordance with the Rule Book
GERT8000 Module TW1 ‘Preparation and movement of trains’ (issue 17, September 2021).
Report 14/2023                                          17                                         December 2023
London Gateway
                                                                                                                      LG11 signal
The sequence of events
Summit                                                                    Scanners
                                                                                                                 Point of                      and camera
                         30
                                                                                                               derailment                      equipment
                         25
20
15
10
5
0
                              0                   500               1000           1500                     2000        2500                 3000          3500
                              Distance from Thames
                              Haven Junction (metres)                           Single brake                          Double brake
                                                                                applications                           application
                                     Speed (mph)                                Permanent speed restriction (mph)           Brake pipe pressure (bar)
Locomotive brake cylinder pressure (bar)   Traction (throtle number)                   Track elevation (metres)
Train 4L47                                 Wagon 12 (lead bogie)
Figure 5: Analysis of the locomotive OTDR for the journey along the Down Thames Haven line.
37 Train 4L47 passed over Thames Haven Junction at around 22 mph (36 km/h).
                            The locomotive OTDR recorded a mixture of traction effort demands and single
                            brake applications as it continued to the summit and then descended the 1 in
                            108 gradient to LG11 signal. The driver recalled the signal clearing as the train
                            approached. The OTDR recorded two consecutive brake applications (a ‘double
                            brake application’) shortly after the front of the train passed the signal. At this
                            time, wagon 12 was approaching the point of derailment. Together with the
                            derailment marks and other evidence (see paragraphs 42-44), the OTDR analysis
                            shows that the leading bogie on wagon 12 derailed as the brakes were releasing
                            after the second of the two brake applications.
                         38 The driver recalled a sudden jolt and, looking back, noticed dust coming from the
                            train. On realising something was wrong, they brought the train to a stand.
                         Events following the accident
                         39 The driver secured the train and walked back to confirm what had happened.
                            On returning to the cab, they made a GSM-R call to the signaller to report the
                            derailment. The signaller notified the London Gateway rail control centre. A
                            member of ground staff arrived, and both they and the driver acted to protect the
                            train.
                         40 After the accident, the driver was tested for the presence of both non-medical
                            drugs and alcohol at London Gateway port. The driver tested clear for both.
                         41 It was 14 days before temporary repairs could be made to the railway and the
                            rail connection into the London Gateway port reopened. An assessment of final
                            infrastructure repairs identified the need for extensive renewal work including the
                            replacement of nearly 700 metres of track and the installation of a complete new
                            set of points.
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Background information
Background information
Examination of the track and derailment site
42 Marks and damage on the track were found on the approach to LG11 signal. They
   were consistent with:
     • both left-hand wheels on a single bogie lifting up onto the rail
     • the left and right-hand wheels of both wheelsets then becoming airborne for
       around two metres
     • the right-hand wheels then landing on the sleepers between the rails (the
       ‘four- foot’) and the left-hand wheels landing in the track bed alongside the
       railway (the ‘cess’).
43 The first identified derailment mark was on the left-hand rail, approximately
   11 metres on the approach to LG11 signal. This was designated the point of
   derailment and numbered as sleeper 0.8 The second derailment mark was
   identified at sleeper -3, around 2 metres beyond the point of derailment (figure 6).
   The separation of the marks was consistent with the 1.8 metre wheelbase of the
   TF20 bogies fitted to wagon 12 (see paragraphs 49 and 58). This, and the form
   of the marks (short, and at an angle to the rail), shows that both wheelsets on the
   same bogie had lifted suddenly, and simultaneously left the track on a trajectory
   towards the left.
First landing marks
Sleeper -3
~2 metres
                                                                                                    Direction
                                                                                                    of travel
Point of derailment
                                                                                         (sleeper 0)
Figure 6: Derailment marks and track damage in the vicinity of the designated point of derailment
(photographs courtesy of Network Rail).
8
  The sleepers were sequentially numbered as part of the track examination, with sleeper 0 being the nominal point
of derailment and negative numbers indicating sleepers beyond this point.
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                         44 Other marks were found further along the track. These took the form of damage
Background information
to sleepers in the four-foot and cess. There was an absence of marks between
                            sleeper 0 and sleeper -3, evidence of one wheelset running derailed between
                            sleeper -3 and sleeper -6 and, after this, evidence of two wheelsets running
                            derailed. This indicates that the two wheelsets on the bogie landed more or
                            less at the same time, the leading wheelset close to sleeper -6 and the trailing
                            wheelset close to sleeper -3. They had remained airborne in the meantime
                            (figure 7). There were no marks to suggest that more than one bogie ran derailed
                            on the Down Thames Haven line. RAIB has concluded, from other evidence, that
                            the wheelsets which derailed at this point were on the leading bogie of wagon 12
                            (see paragraph 66).
Landing mark -
                                   LG11 signal                                                        leading wheelset
Sleeper -6
                                                                                                       Landing mark -
                                                                                                      trailing wheelset
Sleeper -3
                                    Direction
                                    of travel
Figure 7: Derailment marks and track damage on the approach to LG11 signal and The Bridleway level
                         crossing beyond (photograph courtesy of Network Rail).
45 Closed-circuit television (CCTV) images from the lineside cameras (paragraph 30)
                            showed that three bogies in total had derailed by the time wagon 12 was running
                            on the Thames Haven Single line (figure 8). These were the trailing bogie on
                            wagon 11 and both bogies on wagon 12. All three of these bogies were shown
                            running derailed to the left. RAIB concluded that the trailing bogie on wagon 12
                            and the trailing bogie on wagon 11 had been drawn into derailment due to the
                            path that the already derailed leading bogie of wagon 12 was forced to take as it
                            ran through LG1 points, where the Up Thames Haven and Down Thames Haven
                            lines join to form the single line (paragraph 13). Marks and damage on the track
                            at LG1 points support this.
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                                                                                                      Background information
                              Wagon 12 -
                              leading bogie
Wagon 11 -                Wagon 12 -
                               trailing bogie            trailing bogie
Figure 8: CCTV images of train 4L47 passing the London Gateway port cameras and OCR scanners
(images courtesy of DP World).
46 When the derailed train reached LG2 points, the leading bogie on wagon 11 and
   both bogies of wagon 13 also derailed (figure 9).
Wagon 13                    Wagon 12                           Wagon 11
Direction of travel
Figure 9: Final position of Wagons 11, 12 and 13 (photograph courtesy of VTG Rail).
Ecofret 2 wagons
47 Intermodal wagons operating on the mainline railway in Great Britain (GB)
   have been historically designed to accommodate container payloads of up
   to 60 feet (18.3 metres) in length. This means that they can typically carry a
   40- foot container plus a 20-foot container, three 20-foot containers or two 30-foot
   containers. Examples of such wagons include the FEA type wagons within train
   4L47.
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                         48 With 40-foot containers becoming more popular (and 20 and 30-foot containers
Background information
becoming scarcer), freight train operators were finding many of their wagons
                            were carrying solitary 40-foot containers, resulting in wasted capacity. VTG Rail
                            identified a market for a shorter intermodal wagon that carried only a single
                            40- foot container.9 This led to it contracting an engineering consultant to design
                            the Ecofret 1 wagon. A prototype Ecofret 1 triple-wagon was in built in 2012, with
                            Ecofret 1 production versions being built both in triple-wagon and twin-wagon
                            configurations.
                         49 A continuing demand for intermodal wagons led to the development of the Ecofret
                            2 wagon, based on the earlier Ecofret 1 design. VTG Rail identified that the
                            following changes to the Ecofret 1 design were needed:
                               • A bogie that would enable compliance with new ride requirements.10 VTG Rail
                                 opted to specify a bogie of the TF20 type that Wabtec was in the process of
                                 developing.
                               • Brake equipment from a different supplier. The aim was to avoid problems that
                                 had been experienced with the brake equipment fitted to Ecofret 1 wagons.
                               • Flexibility to carry one 40-foot or two 20-foot containers on any of the three
                                 wagons (rather than only the centre wagon which Ecofret 1 allowed) of a
                                 triple- wagon.
                         50 In other areas it was decided to keep the wagon designs as similar as possible.
                            This was to aid maintenance and spares management. The objective of
                            minimising change led to VTG Rail deciding to specify the same longer bar
                            coupler that had been retrofitted to Ecofret 1 triple-wagons during early service
                            (see paragraphs 76 and 77).
                         51 VTG Rail led a team to project manage the various development tasks and
                            engaged consultants to assist. The team included representatives from its
                            suppliers, Wabtec and WH Davis. The division of the engineering responsibility
                            can be summarised as below:
                               • VTG Rail – wagon technical specification and overall design, and the
                                 management of the approval work needed
                               • WH Davis – modifications of the Ecofret 1 wagon underframe design including
                                 incorporation of the new brake equipment, the revised container securing
                                 arrangements and the interfaces for the TF20 bogie
                               • Wabtec – design and development of the TF20 bogie and work needed to
                                 demonstrate compliance with wagon ride and running safety requirements that
                                 were identified as relevant.
                         52 Figure 10 shows the three wagons making up a typical Ecofret 2 triple-wagon.
                            Each has a welded steel underframe comprising a central longitudinal rectangular
                            box (the ‘underframe spine’) from which the bolster, headstock and other
                            fabrications provide the interfaces for the bogies, couplers and buffers, brake
                            equipment and the spigots needed for securing the containers.
9
                          The ability to carry two 20-foot containers was also required, but this flexibility was only provided on the centre
                         wagon of an Ecofret 1 triple-wagon.
                         10
                             VTG Rail identified Railway Group standard GM/RT2141 issue 4 as an applicable requirement. This introduced
                         the need to demonstrate that vehicles are not at risk of derailment due to repeated vertical track geometry
                         irregularities (also known as ‘cyclic top’).
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                                                                                                                    Background information
                                            Bolster
                                                           Underframe spine
                                 Spigot
Brake equipment
Outer headstock                       Inner headstocks                      Outer headstock
Outer wagon                         Centre wagon                          Outer wagon
Figure 10: An Ecofret 2 triple-wagon.
53 The bar couplers that connect Ecofret 2 triple-wagons together (paragraph 26)
   are anchored within a central pocket on the inner headstocks (the ‘headstock
   pocket’). With reference to figure 11, the bar coupler arrangement comprises
   a rigid drawbar11 (1) that connects to spring units (2), one on each wagon, via
   spherical bearings (3). Each spring unit is made up of three elastomeric ring
   elements. These are preloaded by being clamped between two steel plates
   (4), which locate and secure each spring unit within the headstock pocket (5).
   The spring units enable the drawbar couplings to compress (or extend) when
   the externally applied longitudinal force exceeds the preload amount in either
   compression (causing the coupled wagons to draw closer together) or tension
   (causing the coupled wagons to separate). The material used in the spring
   components enables the bar coupler arrangement to absorb energy when
   alternating forces apply.
54 The spherical bearings allow the rigid drawbars to pivot in both the vertical
   longitudinal (‘pitch’ rotation) and horizontal (‘yaw’ rotation) planes. Relatively large
   angles of movement are possible. No mechanism or design feature is provided
   to restrict these rotations before the rigid drawbar contacts the sides, or top and
   bottom, of the headstock pocket.
55 The outer wagons are nearly a metre longer than the centre wagons. This is
   to accommodate the conventional screw coupling and side buffer arrangement
   needed to couple to other vehicles (paragraph 26). With reference to figure 12,
   the arrangement comprises a conventional draw hook and screw coupling (6).
   This connects to a drawgear spring unit (7) on the outer headstock via a clevis
   and pin (8). The drawgear spring unit comprises two side-by-side stacks of
   elastomeric ring elements. These are also preloaded. Conventional buffer units
   (9) with internal spring elements (10) are bolted to the outer headstock, one on
   either side.
11
     1.6 metres long, as adopted for the lengthened Ecofret 1 bar coupler arrangement (see paragraphs 76 and 77).
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                                                                                              1.60 m
Background information
5.Headstock
                                                         2. Spring unit                                                        pocket
3. Spherical
                                                                                             bearings
1. Rigid
                                                                                              drawbar
                                                        4. Steel plates
                         Figure 11: Bar coupler arrangement at the inner headstock locations. Photograph shows the general
                         arrangement and the space available for pitch and yaw rotation within the headstock pocket.
9. Side buffer unit
7. Drawgear
                                                                                                                           spring unit
                                                                                       6. Drawhook
                                                                                        and screw
                                                                                         coupling
8. Clevis
                                                                                                  and pin
10. Spring elements
                         Figure 12: Screw coupling and side buffer arrangement at outer headstock locations. Photograph shows
                         the general arrangement when coupled to another vehicle – a class 66 locomotive.
56 When coupled, the link on the screw coupling is placed on the draw hook of the
                            other vehicle (or vice versa) and the screw coupling tightened. If this results in
                            the buffer faces being in contact (without buffer unit compression),12 then any
                            longitudinal compressive force generated along the train will act only on the buffer
                            unit pairs, with the coupled vehicles coming closer together as the buffer units
                            deflect. Insufficient tightening of the screw coupling results in a gap between the
                            buffer faces. This is referred to as ‘slack’, which needs to be taken up (closed)
                            before the buffer units can touch and start to deflect.
                         12
                            The discussion on the behaviour of a screw coupling and side buffer arrangement relates to operation on
                         nominally straight track. It does not take into account effects such as vehicle yaw rotation that occurs on curved
                         track.
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57 With the buffer faces in contact (but without buffer unit compression), any
Background information
   longitudinal tensile force generated acts only on the connected drawgear spring
   unit pairs. In this case, the coupled vehicles will separate, but only once the
   drawgear spring unit preload is overcome and the drawbar spring units can
   start to deflect. If any slack was present (buffer faces not in contact), then this
   would need to be taken up before this force can act. The material in the spring
   components enables the arrangement to absorb energy when alternating forces
   apply.
58 The TF20 bogie (figure 13) has a fabricated steel bogie frame supported by four
   coil spring primary suspension units, one at each axlebox, with the axleboxes
   being also connected to the bogie frame via a primary traction rod arrangement.
   The bolster on the wagon underframe is supported by a pair of rubber secondary
   suspension springs. Primary and secondary hydraulic dampers are fitted to help
   control dynamic behaviour. The bogie is designed to run with the ‘P8’ type wheel
   profile that was developed by British Rail.
Secondary          Secondary
                                                                suspension spring suspension damper
Primary                 Primary           Primary
 suspension                traction        suspension
     unit                    rods            damper
Figure 13: TF20 bogie.
Ecofret 2 wagons - design approval and maintenance
59 In September 2019, VTG Rail drafted a document setting out its strategy for
   obtaining authorisation from the Office of Rail and Road (ORR)13 for placing
   Ecofret 2 wagons into service on the GB mainline railway. This included
   demonstrating that the wagons complied with technical specifications for
   interoperability (TSI) and national technical rules (NTR), as was then required by
   The Railways (Interoperability) Regulations 2011.14 VTG appointed ACS to act as
   both the Notified Body15 (NoBo) and Designated Body16 (DeBo) for the verification
   work required.
13
     The safety authority for railways in Great Britain.
14
     https://www.legislation.gov.uk/uksi/2011/3066/contents/made.
15
   A body which assesses and verifies the conformity of projects and systems to TSIs. TSIs have now been
replaced in the UK by National Technical Specification Notices (NTSNs). The assessment and verification of
conformity to NTSNs is by an Approved Body (ApBo). ACS also carried out this independent assessor role. https://
www.orr.gov.uk/sites/default/files/2021-07/guidance-on-approach-to-authorisation-under-the-interoperability-
regulations.pdf.
16
     A body which assesses and verifies the conformity of projects and systems to NTRs.
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                         60 VTG Rail also recognised that the new Ecofret 2 wagons constituted a significant
Background information
change under the Common Safety Method on Risk Evaluation and Assessment17
                            (CSM REA), primarily due to the change of bogie. Because of this, they needed
                            to carry out a programme of hazard identification (recording the identified hazards
                            in a hazard log), risk evaluation and hence demonstrate that risks were managed.
                            VTG Rail appointed ACS to act as the Assessment Body (AsBo) to undertake the
                            required independent assessment of compliance with the CSM REA.
                         61 Ecofret 2 wagons were to be the first wagons to use the new TF20 bogie. Wabtec
                            sought to use this opportunity to gain approval for the bogie as an ‘interoperability
                            constituent’.18 The intent of this was to avoid extensive additional testing and
                            analysis work when supplying the bogie to other wagon manufacturers. Wabtec
                            carried out the approval work for the bogie, arranged for its assessment and
                            obtained approval certificates. These certificates were referenced by ACS as
                            evidence of compliance within the overall wagon approval documentation.
                         62 Wabtec used an industry-standard railway vehicle dynamics computer simulation
                            package to help assess compliance with requirements for dynamic behaviour
                            and safety against derailment on twisted track.19 This only required development
                            and validation of computer simulation models that represented Ecofret 2 wagons
                            as single vehicles. No need was identified to develop a simulation model
                            representing a coupled triple-wagon. Supporting analysis work identified a running
                            behaviour issue that led Wabtec to conclude that special devices were needed to
                            control primary lateral suspension movement. It was this that resulted in Wabtec
                            making a late modification to the TF20 bogie (see paragraph 67).20
                         63 On 30 March 2021, ORR issued an ‘authorisation to place into service’ for
                            the batch of Ecofret 2 wagons that included wagons 11, 12 and 13 of train
                            4L47. ORR can only issue this where an applicant has satisfied ORR that the
                            ‘project sub-system’ (in this case the Ecofret 2 wagon) is technically compatible
                            with the railway on which it is to operate, that the various required tests have
                            been satisfactorily completed and that the relevant supporting information
                            and documents have been drawn up or prepared.21 The batch comprised 84
                            triple- wagons, or 252 wagons in total.
                         64 VTG Rail’s inspection and maintenance regime for Ecofret 2 wagons comprised
                            a weekly in-service inspection, which is essentially a visual examination of the
                            overall wagon condition, and a more detailed annual vehicle inspection and
                            brake test (VIBT). The triple-wagon comprising wagons 11, 12 and 13 entered
                            service on 19 April 2021. The first VIBT was not due until 19 April 2022, after the
                            derailment.
17
                            A regulation which describes how the safety impacts of significant changes are assessed. https://www.orr.gov.uk/
                         sites/default/files/2023-07/common-safety-method-for-risk-evaluation-and-assessment.pdf.
                         18
                            A component, group of components or assembly of equipment that is incorporated or intended to be
                         incorporated into a subsystem upon which the interoperability of the rail system depends directly or indirectly. The
                         concept of a constituent includes both tangible objects and intangible objects such as software.
                         19
                           Chapters 4, 5, 6.1 and 7 of BS EN14363:2016 ‘Railway applications – Testing and Simulation for the
                         acceptance of running characteristics or railway vehicles – Running Behaviour and stationary tests’.
                         20
                           Wabtec explained that when no payload was carried (‘tare condition’), these devices were not required at speeds
                         below 50mph (80 km/h).
                         21
                              ‘Approach to authorisation under the Interoperability Regulations’, Guidance to Applicants, ORR, 2021.
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Examination of the derailed wagons
Background information
65 RAIB examined wagons 11, 12 and 13 (which together formed a Ecofret 2
   triple-wagon). It recorded the condition of the suspension, wheels, bogie brake
   equipment and couplers and found that the damage to the wheel treads and
   flanges and the brake equipment was consistent with all the bogies of these
   wagons having run derailed. RAIB also measured the wheel profiles and relevant
   wheelset dimensions for use in subsequent wagon derailment simulation studies
   (see paragraph 82c and appendix D).
66 RAIB identified witness marks on the headstock pockets where wagon 11 and
   wagon 12 were coupled together (figure 14). The marks were consistent with
   the leading end of wagon 12 running derailed to the left and the rigid drawbar
   coming in to contact with the headstock pockets as a result. The marks were only
   found on one side of the headstock pockets. From this, and the available CCTV
   evidence (paragraph 45), RAIB has concluded that the leading bogie of wagon 12
   was the first to derail.
Contact                                No           Contact                              No
 damage                               damage         damage                             damage
  on left                                            on right
Wagon 11 inner headstock (trailing end)             Wagon 12 inner headstock (leading end)
Figure 14: Witness marks on the headstock pockets on wagon 11 and wagon 12 after recovery (rigid
drawbar is shown disconnected from wagon 11, and after a weld repair had been done).
67 Special suspension movement control devices were added to the TF20 bogie as
   a late modification (paragraph 62). Referred to as ‘primary lateral buffers’ (PLBs),
   they comprise a sliding frame designed to capture and restrain a vertical metal
   lug on top of each axlebox. The lug is informally known as the ‘shark fin’. With
   reference to figure 15, the sliding frame (11) is secured to the underside of the
   bogie frame, the shark fin passing through a rectangular void (12). Two friction
   strips (13) attached to the sliding frame are designed to bear against the sides
   of the shark fin. These allow the shark fin (and axlebox) to slide up and down.
   The side-to-side (lateral) movement of the axlebox is restrained by two laminated
   elastomeric springs (14).
68 RAIB identified signs of significant damage and degradation on several PLBs. On
   wagon 12, nearly all the friction strips had detached and there was evidence that
   some of the laminated elastomeric springs had split. Degradation of the PLBs on
   Ecofret 2 wagons was a problem that existed before the derailment, and work
   was being carried out to investigate it when the derailment occurred.
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Background information
13. Friction strips                       11. Sliding frame            Friction strips missing
14. Laminated                        12. Rectangular void (to
                          elastomeric springs                   accommodate the shark fin)                     Shark fin on axlebox
                         Figure 15: Primary lateral buffer device (diagram courtesy of VTG Rail). Photograph shows the
                         condition of a PLB device as found on wagon 12.
Derailment risk due to longitudinal train dynamics
                         69 Design and operational issues associated with longitudinal train dynamics have
                            long been recognised as factors affecting derailment risk. British Rail’s internal
                            derailment investigation guidance from the 1980s22 provides useful historical
                            context. It mentions traction and braking effects, buffer interaction, and coupling
                            tightness as important influences.
                         70 RAIB has investigated one previous derailment event where longitudinal
                            train dynamic behaviour was identified as a factor, at Neville Hill depot on
                            13 November 2019 (RAIB report 13/2020). The accident involved a relatively
                            new Intercity Express Train which collided at low speed with the rear of another
                            train moving in the same direction. The longitudinal compressive forces that were
                            generated resulted in wheelsets on the Intercity Express Train derailing to the
                            side by up to 1.25 metres, on three separate vehicles.
                         71 Following discussions with RSSB, RAIB has concluded that the rail industry
                            maintains an awareness that such issues can affect the safe running of freight
                            trains. However, there has been little recent rail industry research aimed at
                            understanding the risks relevant to current freight operations, or developing
                            guidance, processes, or standards to manage them.
22
                              ‘A guide to the investigation of derailments’, 5th edition, British Railways Board, 1985.
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72 The wagons involved in this derailment were of a type that is currently outside the
Background information
   scope of European Standard BS EN15839:2012, ‘Railway Applications – Testing
   for the acceptance of running characteristics of railway vehicles - Freight wagons -
   Testing of running safety under longitudinal compressive forces’.23 This European
   standard is identified in the TSI for freight wagons (WAG TSI) as an ‘additional
   optional condition’ which defines an acceptance criteria for vehicles with standard
   side buffers and screw couplings which are operated in trains where ‘high
   longitudinal compressive forces may occur’. The standard cites S-shaped curves
   (where side buffer contact could occur) to be the special concern and specifies
   a test track comprising curves of 150 metre radius separated by a nominal
   6-metre-long straight section. There are plans to revise this European standard to
   incorporate wagons of the type that were first to derail at London Gateway (see
   paragraph 152).
Previous derailments involving Ecofret 1 and Ecofret 2 wagons
73 Two derailments of Ecofret 1 triple-wagons occurred after they entered service, at
   Felixstowe on 28 August 2015 and at Peterborough on 17 September 2015 (see
   paragraphs 174 and 175). The two trains were of similar length, and both were
   braking at the time. In each instance, the triple-wagons that derailed were in the
   middle part of the train, with the centre wagons carrying no load. Nearly all the
   other wagons on the trains were loaded. Neither derailment occurred on Network
   Rail managed infrastructure.
74 GBRf and VTG Rail investigated both derailments and identified that high
   longitudinal compressive forces were the likely cause. VTG Rail subsequently
   commissioned a vehicle dynamics specialist to undertake detailed computer
   simulations to understand the effect of longitudinal compressive forces on Ecofret
   1 triple-wagons. It used the same vehicle dynamics computer simulation package
   that was used in this investigation to evaluate the susceptibility of wagon 12 to
   derailment by this means (see paragraph 82c). The simulations included the effect
   of track geometry irregularities.
75 The centre wagon was found to be most prone to derailment by this means. VTG’s
   specialist reported that an increasing longitudinal compressive force resulted in:
     • the wagon underframes initially rotating when viewed from above (yaw rotation),
       all in the same direction
     • the flanges of the left-hand wheels on the leading bogies then contacting the rail,
       with the flanges of the right-hand wheels on the trailing bogies doing the same
     • the wheel flanges being further pressed into rail contact as the developed lateral
       forces increased, and the wheelsets on the most prone bogie (in some cases
       the leading bogie on the centre wagon, in others the trailing bogie) starting
       to roll about the wheel flange-rail contact point with the wheel opposite to the
       contacting wheel then lifting off the rail
     • the whole bogie then finally lifting and derailing.
     The longitudinal compressive forces were simulated by applying equal and
     opposite end loads on the outer wagons.
23
   BS EN 15839:2012 lists ‘permanently coupled units with a bar coupler between the vehicles’ as one of the types
of vehicles that are out of scope.
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                         76 VTG Rail’s engineering consultant (paragraph 48) later developed a simulation
Background information
model that was simpler, and which became referred to as the ‘quasi-static model’.
                            The consultant concluded that, for an Ecofret 1 triple-wagon, the quasi-static
                            model predicted similar behaviour to the earlier detailed computer simulations.
                            Other simulations using the quasi-static model suggested an Ecofret 1
                            triple- wagon was more susceptible to derailment than an Ecotfret 1 twin-wagon.
                            The quasi-static model was also used to evaluate options for improving the
                            derailment resistance. It included work supporting a decision to lengthen the bar
                            coupler.
                         77 The decision to change the bar couplers on Ecofret 1 triple-wagons was recorded
                            in engineering documentation issued in March 2017. VTG Rail explained that an
                            operating restriction was imposed until the modification work was complete. This
                            restriction was intended to prevent Ecofret 1 triple-wagons from running in certain
                            payload conditions identified as making derailment more likely. VTG Rail reported
                            that Ecofret 1 wagons have operated without incident since the modification was
                            implemented.
                         78 A collision involving a GBRf intermodal train and agricultural equipment at Kisby
                            user worked crossing on 19 August 2021 resulted in the derailment of an Ecofret
                            2 triple-wagon (RAIB Report 12/2022). The collision occurred on a section of
                            nominally straight track, with the Ecofret 2 triple-wagon being part way along the
                            train and none of the wagons carrying a container. The Ecofret 2 triple-wagon
                            derailed in the same manner as an Ecofret 1 triple-wagon was predicted to under
                            longitudinal compressive force (paragraph 75), with the wheels on the leading
                            bogie of the centre wagon derailing to the left and the wheels on the trailing bogie
                            derailing to the right (figure 16).
Outer wagon                              Centre wagon                        Outer wagon
Direction of travel
Figure 16: Ecofret 2 triple-wagon that derailed at Kisby on 19 August 2021.
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79 The damage to the front of the train at Kisby indicates that significant longitudinal
Background information
   compressive forces were generated in the accident, just as they were during
   the collision at Neville Hill depot (paragraph 70). Therefore, this damage, the
   observed position of the wheels after derailment and the design similarities
   between Ecofret 1 and Ecofret 2 triple-wagons have led RAIB to conclude
   that the derailment of the wagon at Kisby was probably caused by longitudinal
   compressive force.
Testing and analysis
80 The accident at Kisby demonstrated the probability of an Ecofret 2 triple- wagon
   derailing in a similar manner to that seen at London Gateway because of
   longitudinal compressive force. However, unlike Kisby, no collision occurred
   at London Gateway, and therefore, for longitudinal compressive force to have
   initiated this derailment, it needed to have been generated in another way.
   Longitudinal train dynamic effects due to brake applications were identified
   as the reason for the unsafe longitudinal compressive forces in the Ecofret
   1 triple- wagon derailments at Felixstowe and Peterborough. Given the
   brake application changes at the time of the derailment at London Gateway
   (paragraph 37), this was identified by RAIB as a potential cause of the derailment
   of wagon 12.
81 The simulation models developed by VTG Rail’s vehicle dynamics specialist
   and its engineering consultant both predicted that longitudinal compressive
   forces of around 400 kN24 would be sufficient to cause an Ecofret 1 triple- wagon
   to derail with bar couplers of the original length (paragraphs 74 and 76). In
   seeking to compare this with the longitudinal compressive forces likely to be
   experienced in service, VTG Rail’s engineering consultant hypothesised a
   worst-case force of around 500 kN during braking. However, this hypothesis
   largely relied on assumptions and simplifications relating to retardation rates and
   speed- dependent braking effects published in RSSB research.25 This meant that
   the supporting analysis could not be extended and used to establish how the
   actual brake applications, made around the time that train 4L47 derailed, related
   to the nature and significance of the longitudinal compressive forces generated.
82 Understanding the nature of the actual braking forces acting along train 4L47 (and
   the traction forces provided by the locomotive), their effect on the longitudinal train
   dynamics, and ultimately the risk of derailment, became critical to determining the
   likelihood of the derailment having been caused by this mechanism. Developing
   this understanding involved:
        a. Estimating the brake and traction torques acting on the wheelsets of the
           locomotive and the individual wagons of train 4L47 and how these varied as
           the train travelled along the Down Thames Haven line. These are referred to
           in this investigation report as the ‘locomotive brake torque time history’, the
           ‘locomotive traction torque time history’ and the ‘wagon brake torque time
           history’. Their derivation involved use of measurements made on the brake
           system of representative test trains and data from the OTDR on train 4L47
           recording how it was operated. Appendix B contains further explanation on
           how the estimated torque time histories were derived, and the testing involved.
24
     A force of 10 kN is approximately equal to the weight of a mass of one tonne.
25
   RSSB report, T999-01 ‘Review of braking tables in RGS GK/RT0075 Lineside signal spacing and speed
signage’.
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                             b. Determining how the derived traction and brake torque time histories affected
Background information
the longitudinal compressive forces generated within train 4L47 as it travelled
                                along the Down Thames Haven line. This involved the development of a
                                computer model to simulate the longitudinal train dynamic behaviour of train
                                4L47. This was then used to undertake baseline simulations and sensitivity
                                studies to understand how longitudinal compressive force (determined from
                                the forces calculated in the couplers connecting the locomotive and wagons
                                together) was affected by factors including coupler characteristic and brake
                                application. Appendix C includes further explanation on how the computer
                                model was developed and the findings from the baseline simulations and
                                sensitivity studies.
                             c. Evaluating the susceptibility of wagon 12 to derailment under longitudinal
                                compressive force. This involved the development of a vehicle dynamics
                                simulation model representing the complete Ecofret 2 triple-wagon comprising
                                wagons 11,12 and 13, and use of this to understand the behaviour of wagon
                                12 when a longitudinal compressive force is suddenly applied, the derailment
                                sequence and the forces associated. Appendix D includes further explanation
                                on how the wagon derailment simulation model was developed and the
                                findings from the baseline simulations and sensitivity studies.
                         Train braking
                         83 All the wheels on train 4L47 were braked using a conventional single pipe
                            automatic air brake system. With reference to figure 17, the system comprises
                            a distributor valve (15) and an auxiliary air reservoir (16) on the locomotive and
                            each wagon. These are connected by a single brake pipe (17) that runs the length
                            of the train, with flexible hoses (18) provided between the individual vehicles.
                            Brakes blocks on each wheel (19) apply when the distributor valves feed air to the
                            brake cylinders (20) from the auxiliary air reservoirs.
                         84 The automatic air brake is controlled from the driver’s brake valve (21) in the
                            locomotive cab. The driver’s brake valve is used to vary the pressure in the
                            brake pipe, either by venting the brake pipe or by feeding it with air from the main
                            air reservoir (22). The brake distributor valves vary the pressure in the brake
                            cylinders (and therefore the force applied to the brake blocks) depending on the
                            brake pipe pressure. The brakes are released (no pressure in the brake cylinders)
                            when the brake pipe is fully charged (at nominally 5 bar). A full service brake
                            application is made when the brake pipe is vented to a pressure of approximately
                            3.35 bar. An emergency brake application is made when it is fully vented (zero
                            pressure). The automatic air brake system is charged from an air compressor on
                            the locomotive (23).
                         85 The brake pipe pressure signal needs to propagate along the length of the train
                            and command the individual distributor valves to vary the local brake cylinder
                            pressure. This means that on a long train it can take several seconds more for the
                            brakes to apply (or release) on a wagon at the rear of the train compared to the
                            front. This can lead to a significant variation in braking force along the train.
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86 Brake distributor valves have a set of chokes that can be set to either ‘passenger’
Background information
   or ‘goods’ settings. In the passenger setting, the train can stop in a shorter
   distance because the wagon brakes apply more quickly. In the goods setting a
   slightly delayed brake application is made. This helps ensure that the brakes on
   the wagons throughout a long freight train apply in a more consistent manner.
   The brake distributor valves on train 4L47 were all in the passenger setting.
   This was so the train was able to achieve the braking performance needed to be
   compatible with its maximum operating speed, which was 75 mph (121 km/h),
   and the signal spacing on the route.
Wagon                                        Locomotive
                                                                    21. Driver’s brake valve
                                                               22. Main air reservoir
                                                             23. Air compressor
                   17. Brake pipe
To next
wagon
15. Distributor                                          20. Brake
             valve                                                     cylinder
                                                    18.
                                                  Flexible
                                                   Hose
                            19. Brake block                                       16. Auxilliary
                            and wheel                                             air reservoir
Figure 17: Single pipe automatic air brake system (simplified).
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           Analysis
Analysis
Identification of the immediate cause
           87 Longitudinal compressive forces generated within train 4L47 during braking
              were sufficient to cause the wheels on the leading bogie of wagon 12 to
              suddenly lift and run derailed.
           88 The witness marks on the track (paragraphs 42 to 44), CCTV images from the
              port lineside cameras (paragraph 45), and the contact damage to headstock
              pockets from the bar coupler between wagon 11 and wagon 12 (paragraph 66),
              were all consistent with:
                 • the left-hand wheels on the leading bogie of wagon 12 rapidly and
                   simultaneously contacting the left-hand rail and then lifting over the railhead
                 • both bogie wheelsets then becoming airborne, landing to the left and running
                   derailed parallel to the track.
           89 The derailments at Felixstowe, Peterborough and Kisby (paragraphs 73 and 78)
              had significant similarities with the circumstances and outcome of the derailment
              at London Gateway. All three involved FWA type triple-wagons (either Ecofret 1 or
              Ecofret 2) that were in the middle part of the train, and the individual wagons were
              connected using the same (or near identical) bar coupler arrangement. The first
              wagons to derail were unloaded centre wagons and there is evidence suggesting
              that the wheels derailed rapidly, probably by lifting,26 when significant longitudinal
              compressive forces would have been suddenly generated (either during braking
              or as the result of a collision). This supports the conclusion that wagon 12 was
              susceptible to derailment by this means.
           90 The wagon derailment simulations undertaken in support of the investigation of
              this derailment (paragraph 82c and appendix D) predicted behaviour that was
              consistent with the characteristics of these earlier derailments. In summary, and
              with reference to figure 18, as a sustained longitudinal compressive force of
              increasing magnitude was suddenly applied:
                 • The underframe of wagon 12 started to lift (stage A).
                 • The underframe of wagon 12 then started to rotate when viewed from above
                   (yaw rotation) (stage B).
                 • As the compressive force was increased further, the wheel flanges on the
                   leading bogie started to contact one of the rails, while on the trailing bogie the
                   wheel flanges started to contact the opposite rail (stage C).
                 • Wheels opposite to the wheel flanges in contact then started to unload,
                   eventually lifting off the rail (stage D).
                 • Finally, one of the bogies rose clear of the rails, derailing fully as a result (stage
                   E, not illustrated).
26
             No wheel flange marks were identified on the railhead at Felixstowe. This suggested to investigators that the
           wheels did not climb over the rail, but rather that they lifted.
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Stage A: Underframe lift
Analysis
                                                                           Direction of travel
Lift                  Lift
Stage B: Underframe yaw rotation
Yaw rotation
Stage C: Wheel flanges in contact with opposite rails
            Trailing bogie right-hand
           wheels forced into contact
Leadling bogie left-hand
                                                         wheels forced into contact
Stage D: Non-contacting wheel starts to lift
Wheel flange                                                                     Wheel
  in contact                                                                    starts to lift
Figure 18: Predicted wagon derailment sequence.
91 VTG Rail’s specialist had predicted similar behaviour for an Ecofret 1 triple-wagon
   in simulation studies undertaken following the derailments at Felixstowe and
   Peterborough (paragraph 75).
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           92 The longitudinal train dynamics simulation studies showed that a high longitudinal
Analysis
compressive force would have been rapidly generated within the train at the time
              of the derailment (paragraph 82b and appendix C). Baseline simulations predicted
              that the maximum longitudinal compressive force occurred as the leading bogie
              of wagon 12 was approaching the point of derailment. Sensitivity studies showed
              that refining the traction and brake torque time histories, so that the calculated
              speed profile better matched that recorded by the locomotive OTDR, significantly
              increased the magnitude of the maximum longitudinal compressive force but did
              not alter its location. Altering the characteristics of the couplers, for instance, by
              introducing the effect of slack (at side buffer and screw coupling arrangements)
              and reducing their capacity to absorb energy was also found to increase the
              magnitude of the maximum longitudinal compressive force, again without altering
              its location. Figure 19 shows the calculated forces in the couplers on wagon 12
              and speed profile for sensitivity study C4. Of the sensitivity studies undertaken,
              this study calculated the greatest maximum longitudinal compressive force
              (451 kN).
           Speed profile (metres per second)
Predicted speed
                                               OTDR speed
                                               Track elevation
                                               Locomotive traction
                                                                                                                           Wagon 12 (lead bogie)
                                                                                                                           at point of derailment
and brake torque
                                                                       Thames Haven Junction
Wagon 12 brake torque
            Coupler force (kN)
Coupler force
                                               wagon 11 to 12
                                               Coupler force                                        Maximum longitudinal
                                               wagon 12 to 13                                       compressive force =
                                                                                                          451 kN
Figure 19: Predicted speed profile and coupler force – sensitivity study C4.
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93 The upper graph plot shows the predicted speed profile and that recorded by
Analysis
   the locomotive OTDR. The track gradient profile and applied traction and brake
   torques (at the locomotive and wagon 12) are shown for pictorial reference. The
   lower graph plot shows the predicted variation of the force in the couplers at
   either end of wagon 12. OTDR analysis shows how the double brake application
   made by the driver of train 4L47 coincided with wagon 12 approaching the
   point of derailment location (paragraph 37). Figure 19 shows that the maximum
   longitudinal compressive force was predicted to occur at the same time. Other
   sensitivity studies show how replacing the double brake application with a brake
   application of different form and size could significantly affect both the magnitude
   and location of the maximum longitudinal compressive force (appendix C).
   Together these show that the high longitudinal compressive force that occurred
   was because of the double brake application and that it is evident that the force
   generated was sufficient to result in the derailment of the leading bogie of wagon
   12.
94 RAIB has investigated several freight derailments on plain line track. It has
   found that these more usually involve conventional flange climb mechanisms
   (such as the derailment at Reading West Junction on 28 January 2012, RAIB
   report 02/2013), or behaviours associated with cyclic top (such as the derailment
   near Gloucester on 15 October 2013, RAIB report 20/2014). RAIB found no
   evidence that the causes frequently associated with these types of derailment
   mechanism were relevant to the accident at London Gateway. Routine track
   geometry measurements had not recorded any significant faults in the vicinity
   (paragraph 29) and the train had not been travelling at a particularly high speed
   (paragraph 9).
95 The longitudinal train dynamics studies predicted a maximum longitudinal
   compressive force location that was consistent with the derailment outcome.
   However, RAIB was mindful that the greatest magnitude calculated (451 kN, for
   sensitivity study C4) was less than the baseline wagon derailment simulations
   predicted as being needed for full derailment (650 kN (see paragraph 119)).
96 RAIB has concluded that the gap between the predictions probably arises from
   data uncertainties and assumptions that were then needed to allow the simulation
   work to proceed. Therefore, the inconsistency is explainable and, given the
   significance of the other supporting evidence (and the lack of evidence supporting
   an alternative derailment means), does not negate the conclusions drawn. RAIB
   did not explore further refinement and validation of the simulation models as
   it considered this would not to be proportionate to the identification of relevant
   safety learning.
97 The significance of the data uncertainties and assumptions is discussed in
   paragraphs 170 to 172.
Identification of causal factors
98 The accident occurred due to a combination of the following causal factors:
    a. Wagon 12 was susceptible to derailment under longitudinal compressive force;
       its condition, and the loading of the Ecofret 2 triple-wagon of which it was a
       part, increased this risk (paragraph 99).
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               b. The longitudinal compressive forces generated within train 4L47 during
Analysis
braking and which acted on wagon 12 were large, significant, and sudden.
                  (paragraph 125).
               Each of these factors is now considered in turn.
           Susceptibility to derailment under longitudinal compressive load
           99 Wagon 12 was susceptible to derailment under longitudinal compressive
              force; its condition, and the loading of the Ecofret 2 triple-wagon of which it
              was a part, increased this risk.
           100 The Ecofret 2 triple-wagon comprising wagons 11, 12 and 13 was a development
               of the Ecofret 1 triple-wagon, a type of triple-wagon that had previously derailed
               on plain line track because of longitudinal compressive forces generated during
               train braking (paragraphs 73 and 74). Although wagon 12 was fitted with the
               longer bar coupler (paragraph 76), this improvement did not fundamentally alter
               the behaviour of the bar coupler arrangement under longitudinal compressive
               force, since the bar coupler remained free to rotate within the headstock pocket
               (paragraph 54). Ecofret 2 triple-wagons remained susceptible to derailing in
               the same way, with a derailment outcome depending on the magnitude (and
               nature) of the longitudinal compressive force, the payload on the three wagons
               (paragraph 77) and the effects of changes introduced as part of the Ecofret 2
               wagon development (paragraph 49).
           101 This causal factor arose due to a combination of the following:
               a. The design process for Ecofret 2 wagons did not fully recognise the need for
                  there to be a change in design from the Ecofret 1 wagon to improve behaviour
                  under longitudinal compressive forces (paragraph 102).
               b. It is possible that degradation and wear had resulted in the bogies on
                  wagon 12 being in a condition that made the wheel flanges more prone to
                  being forced into contact with the rail under longitudinal compressive force
                  (paragraph 117).
               c. The way that wagons 11, 12 and 13 were loaded made the wheels of wagon
                  12 more prone to lifting under longitudinal compressive force (paragraph 121).
               Each of these sub-factors is now considered in turn.
           Wagon design
           102 The design process for Ecofret 2 wagons did not fully recognise the need
               for there to be a change in design from the Ecofret 1 wagon to improve
               behaviour under longitudinal compressive forces.
           103 Earlier derailments and follow-up simulations had led to an understanding of
               the mechanism by which the centre wagon of an Ecofret 1 triple-wagon was
               susceptible to derailment under longitudinal compressive force (paragraphs
               74 to 76). Witness marks and damage to the track and derailed wagons were
               all consistent with a mechanism of this nature resulting in the derailment at
               London Gateway (paragraphs 42 to 44 and 66), while the wagon derailment
               simulations (paragraph 82c and appendix D) further supported this as the
               derailment cause. The derailment at Kisby showed how the centre wagon of
               an Ecofret 2 triple- wagon was similarly susceptible to derailment by this means
               (paragraph 79).
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104 A further conclusion of the early derailment simulation studies was that
Analysis
    triple- wagons of this type are likely to be more susceptible to derailment than
    twin-wagons (paragraph 76).
105 Other options for improvement had been considered before it was decided to
    lengthen the bar coupler on Ecofret 1 triple-wagons. A number of these may have
    benefited the wagon design by changing the fundamental characteristic behaviour
    of the Ecofret 1 triple-wagon under longitudinal compressive force. They included:
    • Fitting side buffers between the centre and outer wagons, either in a
      conventional (two buffer units per headstock) or diagonal (one buffer unit per
      headstock) arrangement. The objective was to provide a means of energy
      absorption that would reduce the effect of the longitudinal compressive force.
      The buffers may also have helped to provide a moment to resist underframe
      yaw rotation (paragraph 90).
    • Fitting cup-and-cone devices between the centre and outer wagons to protect
      against the wagons overriding each other as they get closer together, so in
      effect locking the wagon ends together.
    • Restricting bar coupler rotation by some means, thereby helping prevent the
      coupled wagons coming out of line.
106 All these options were discounted for Ecofret 1 triple-wagons because of the
    complexity of the design and modification work involved. The development of the
    new Ecofret 2, however, presented an opportunity to reconsider improvement
    options. Despite this, design activities and objectives either led to the conclusion
    that the Ecofret 2 triple-wagon would behave satisfactorily under longitudinal
    compressive force or did not result in work that might have indicated otherwise.
    This meant that there was no reconsideration of potential options to improve the
    design’s performance in this respect. The design activities and objectives involved
    are discussed below in more detail (see paragraphs 107 to 116).
Design commonality
107 Other than the bogie and brake equipment changes, VTG Rail sought to keep the
    Ecofret 1 and Ecofret 2 wagon designs as similar as possible (paragraph 50). This
    particularly concerned the wagon underframe and the bar coupler arrangement.
    The technical specification prepared for the Ecofret 2 wagon required the wagon
    underframe to be ‘essentially the same as on Ecofret 1’, with some ‘minor
    change’ needed to accommodate specified equipment differences. It specifically
    required use of the same, longer bar coupler that had been later fitted to Ecofret 1
    triple- wagons.
108 VTG Rail explained that no Ecofret 1 triple-wagons had derailed because of
    longitudinal compressive force after the bar coupler was lengthened. On this
    basis, use of the same, lengthened, bar coupler arrangement was felt to be
    justified for Ecofret 2 triple-wagons.
Design process
109 VTG Rail and its suppliers separately assessed aspects of vehicle behaviour.
    Each used different methods to do so.
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           110 Wabtec focused on the wagon ride and derailment resistance performance
Analysis
(traditionally concerning the risk of derailment by flange climb and cyclic top
               mechanisms) and developed single-vehicle dynamic simulation models to assist
               with this (paragraph 62). Related performance requirements are generally
               specified in TSI and NTR documents, and simulation models of this type are often
               used for assessing and demonstrating compliance.
           111 The assessment of risks due to longitudinal compressive forces was excluded
               from Wabtec’s work. VTG Rail sought to focus on this issue because of its
               overall responsibility for vehicle design (paragraph 51). It used the quasi-static
               simulation model to support this, with VTG Rail asking Wabtec to supply the
               parameter data needed to represent the bogie in the model.27 The need to
               enhance the single-vehicle dynamic model to carry out this assessment was not
               considered necessary. Such a model could have provided greater insight into the
               behaviour of the Ecofret 2 triple-wagon under longitudinal compressive force (see
               paragraph 169).
           Design approval – interoperability requirements and technical standards
           112 VTG Rail identified the standards applicable to its strategy for obtaining
               authorisation for the Ecofret 2 wagon to enter service (paragraph 59). In doing
               this, VTG Rail found no requirement which mandated a demonstration of safe
               running under longitudinal compressive force or any criterion that could have
               been used to assess this and to highlight concern. Its conclusion was consistent
               with a list of standards provided to RAIB that RSSB considered would have been
               applicable.
           113 Criteria for assessing safe running under longitudinal compressive force are
               defined in EN15839 and included as an ‘additional optional condition’ in the
               WAG TSI (paragraph 72). ACS listed the standard in the technical file it prepared
               as part of its NoBo role, but subsequently concluded that compliance was not
               required since the Ecofret 2 triple-wagon was out of scope. Even if the wagon
               had been within the scope of EN15839, RAIB has not been able to determine
               any fundamental changes to the design which are likely to have resulted. This
               is because EN15839 cites operation over S-shaped curves to be the special
               concern, whereas wagon 12 derailed on a section of plain line track comprising
               mainly straight track and plain curves of large radius.
           Design approval – residual risk
           114 ACS reviewed VTG Rail’s hazard log as part of its AsBo role (paragraph 60). It
               identified the risks due to longitudinal compressive force as one of two issues that
               remained open. ORR required the resolution of these issues as a condition of its
               letter authorising the placing into service of the wagons (paragraph 63). VTG Rail
               used the explicit risk estimation approach permitted by CSM REA to develop an
               argument justifying closure.
27
                The outer wagons were treated as being fully loaded and the centre wagon unloaded.
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115 The safety justification that VTG Rail developed was based on a combination of
Analysis
    calculation and evidence of service performance for the Ecofret 1 twin- wagon.
    The quasi-static simulation model had predicted that the longer bar coupler
    increased the capacity of the Ecofret 1 triple-wagon to resist longitudinal
    compressive force from around 400 kN to 600 kN (paragraph 76). However, when
    the same simulation model was used to assess the derailment resistance for
    the Ecofret 2 triple-wagon (paragraph 111), the TF20 bogie parameters meant
    that the capacity to resist derailment due to longitudinal compressive force was
    predicted to be 510 kN, again with the longer bar coupler.
116 VTG Rail’s engineering consultant had hypothesised a worst-case longitudinal
    compressive force during braking of around 500 kN for the Ecofret 1 wagons
    (paragraph 81). In the file note28 that it prepared, VTG Rail stated this to be the
    ‘maximum expected’ longitudinal compressive force ‘to be experienced in service’;
    in an earlier file note29 it argued that the fact that no Ecofret 1 twin-wagon had
    derailed since their introduction in 2012 helped to justify this figure. As this value
    was less than the capacity of 510 kN calculated for the Ecofret 2 design, the
    likelihood of derailment due to longitudinal compressive force was considered
    ‘improbable30’. On this basis, while the severity level was deemed ‘catastrophic’,
    the derailment risk was assessed as being ‘tolerable’.
Bogie condition
117 It is possible that degradation and wear had resulted in the bogies on
    wagon 12 being in a condition that made the wheel flanges more prone to
    being forced into contact with the rail under longitudinal compressive force.
118 Wagon derailment simulations (paragraph 82c and appendix D) established that
    lateral clearances within the bogie primary and secondary suspension needed to
    be taken up before the longitudinal compressive force acting on the bar coupler
    arrangement could result in a wheel flange being brought and forced into rail
    contact. Sensitivity studies showed that the size of the lateral clearances could
    detrimentally affect the capacity of the Ecofret 2 triple-wagon to resist derailment.
119 RAIB identified signs of significant damage and degradation on several PLB
    devices on wagon 12 (paragraph 68). The PLBs were fitted to remedy a running
    behaviour issue that was unrelated to the concerns about the risk of derailment
    due to longitudinal compressive forces (paragraph 62). In the baseline derailment
    simulation case, they were modelled with additional clearance to account for the
    degradation resulting from the detachment of the friction strips, with a longitudinal
    compressive force of 460 kN predicted as being needed for the wheel flanges to
    contact opposite rails (stage C in the derailment sequence (paragraph 90)) and
    650 kN for full derailment (stage E in the derailment sequence). Sensitivity studies
    predicted that when the PLBs were modelled as being intact, the forces predicted
    as being needed increased to 500 kN and 680 kN respectively. This supports the
    degradation of the PLBs reducing the amount of longitudinal compressive force
    required for the wheel flanges to contact the opposite rails, and for a bogie to
    ultimately derail.
28
     VTG Rail file note, FWA-FN10, issue 3.
29
     VTG Rail file note, FWA-FN10, issue 2.
30
     ‘Improbable’ in this context was defined as an event which occurs at intervals between 100 and 1000 years.
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           120 It is possible that some of the PLB damage and degradation observed occurred
Analysis
after the derailment and as a consequence of it occurring. In addition, the
               sensitivity studies suggest that PLB degradation has a much less significant effect
               than other factors such as payload condition (see paragraph 124). However, the
               studies highlight the important role that the bogie suspension is likely to play in
               the resistance to derailment under longitudinal compressive force, particularly
               with respect to the control of lateral suspension movement.
           Payload condition
           121 The way that wagons 11, 12 and 13 were loaded made the wheels of wagon
               12 more prone to lifting under longitudinal compressive force.
           122 Wagon 12 carried no container payload. This was the same loading condition
               as the centre wagons in previous reported Ecofret 1 and Ecofret 2 triple-wagon
               derailments (paragraph 89). This lack of payload resulted in two vulnerabilities
               which made wagon 12 more prone to lifting under longitudinal compressive force
               and its attendant consequences:
                • The lack of payload caused the bar couplers to become inclined, because the
                  outer wagons (wagons 11 and 13) were loaded and therefore lower on their
                  suspension. This provided a line of action resulting in forces that tended to lift
                  the centre wagon (figure 20).
                • The lack of payload reduced the wheel load that the lifting forces needed to
                  overcome.
                Centre wagon (unloaded)                                              Outer wagon (loaded)
                                                Height difference due to
                                                 suspension deflection
                                Lifting force
Suspension deflection     Line of action of       Bar coupler
                 exaggerated           bar coupler force       inclination
           Figure 20: Bar coupler inclination and resulting centre wagon lifting force.
123 The modification to lengthen the bar coupler on the Ecofret 1 triple-wagon
               (paragraph 76) had helped to address the first vulnerability because it reduced
               the angle of inclination and hence the tendency for the centre wagon to lift when
               longitudinal compressive forces were applied. A loading restriction had been
               introduced to manage this vulnerability following the derailments at Felixstowe
               and Peterborough. The bar coupler modification had allowed this restriction to be
               removed (paragraph 77). A loading restriction of this nature was never applied
               to Ecofret 2 wagons, and RAIB found no evidence of any other instruction that
               meant wagons 11, 12 and 13 had been loaded contrary to the rules and guidance
               in force at the time of the accident.
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124 The lightest container on the driver’s train document had a mass of 4.4 tonnes
Analysis
    (table 1). Sensitivity studies predicted that, for this relatively modest payload,
    the longitudinal compressive force needed for the wheel flanges to contact the
    opposite rails (stage C in the derailment sequence) increased to 540 kN (from
    460 kN in the baseline derailment simulation case) and to 930 kN (from 650 kN
    in the baseline derailment simulation case) for full derailment (stage E in the
    derailment sequence) (appendix D). With none of the three wagons loaded, the
    longitudinal compressive forces predicted as being needed increased to 510 kN
    and 850 kN respectively.
Generation of longitudinal compressive force
125 The longitudinal compressive forces generated within train 4L47 during
    braking and which acted on wagon 12 were large, significant, and sudden.
126 Under normal operation, longitudinal train dynamic forces are generated within
    the couplers on a train (such as the bar couplers and the conventional screw
    coupling and side buffers on train 4L47) and act on the individual vehicles at
    the coupler attachment points. The magnitude, sense (compressive, acting to
    squeeze the vehicles together, or tensile, acting to separate the vehicles) and
    variation of these forces depends on the complex interaction of the train’s physical
    properties and the applied forces and torques acting. For long locomotive-hauled
    freight trains, the following elements are important:
    • the traction torques provided by the locomotive that are used to propel
      (accelerate) the train
    • the brake torques that are applied to the wheelsets on the locomotive and each
      wagon to decelerate the train
    • the gravitational forces acting on the locomotive and each wagon as the train
      progresses over the gradient profile
    • the resistance forces acting to slow the motion of the train (for instance, due to
      the effects of track curvature and friction in the axle bearings)
    • the masses of the locomotive and wagons and the rotational inertia of the
      wheelsets (and other rotating parts) that the applied forces and torques need to
      accelerate and decelerate
    • the force-displacement (stiffness), slack and friction properties of the couplers
      that, together with the train mass and inertia properties, help to characterise the
      natural longitudinal dynamic behaviour of the train.
127 Traction torques generally result in longitudinal forces that are tensile. Brake
    torques can result in negligible longitudinal forces if they apply simultaneously on
    each vehicle and are in proportion to the mass of the vehicle being braked. With
    an automatic air brake system, this will rarely be the case because propagation
    and timing effects mean that brake torques do not apply simultaneously along the
    train (paragraph 85). As a result, significant longitudinal compressive (or tensile)
    forces can be generated.
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           128 RAIB sought to characterise and understand the significance of the above
Analysis
elements on the longitudinal compressive forces generated within train 4L47 at
               the time of the derailment by:
                • test and analysis work to estimate the brake and traction torques that were
                  acting along train 4L47 (appendix B)
                • the development and use of the longitudinal train dynamic simulation model
                  (appendix C).
           129 This work provided evidence that:
                a. Wagon 12 was within a part of the train where the longitudinal compressive
                   force generated during braking was likely to be higher than at other locations
                   along the length (paragraph 130).
                b. A double brake application, made shortly after passing LG11 signal, resulted
                   in a sudden and large longitudinal compressive force being generated that
                   acted on wagon 12. This coincided with wagon 12 approaching the point of
                   derailment (paragraph 133).
                Each of these sub-factors is now considered in turn.
           Wagon location
           130 Wagon 12 was within a part of the train where the longitudinal compressive
               force generated during braking was likely to be higher than at other
               locations along the length.
           131 Wagon 12 was in the middle part of the train. The longitudinal train dynamics
               simulation model predicted that, around the time of the derailment, the
               longitudinal compressive forces were highest in the coupler connecting wagons
               16 and 17, which was the coupler at the centre of train 4L47. The longitudinal
               compressive forces acting in the couplers either side of wagon 12 were predicted
               to be only slightly less (figure 21).
Coupler forces:
                                                                    Wagon 12 (leading bogie)
                                                                     at point of derailment
Wagons 11 to 12
                       Wagons 12 to 13
                       Wagons 16 to 17
                       Locomotive to wagon 1
                       Wagons 32 to 33
Figure 21: Predicted variation of the force in the couplers at different positions along train 4L47 around
           the time of the derailment – sensitivity study C4. Plot shows the forces predicted in the couplers: either
           side of wagon 12; between wagons 16 and 17; between the locomotive and wagon 1; and between
           wagons 32 and 33.
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132 While wagon 17 was the centre wagon of an Ecofret 2 triple-wagon, it was
Analysis
    carrying a relatively heavy container (table 1). RAIB concluded that the high
    longitudinal compressive force generated in this part of the train, in combination
    with the lack of container payload (paragraph 121), made wagon 12 particularly
    vulnerable to the effects of longitudinal compressive force. The compressive
    forces in the couplers at the outer ends of the train (between the locomotive and
    wagon 1, and between wagons 32 and 33) were predicted to be negligible by
    comparison.
Train brake application
133 A double brake application, made shortly after passing LG11 signal,
    resulted in a sudden and large longitudinal compressive force being
    generated that acted on wagon 12. This coincided with wagon 12
    approaching the point of derailment.
134 OTDR data from train 4L47 shows three single brake applications being made
    before the double brake application (figure 5). The last two of these were made
    while the train was descending the gradient on the approach to LG11 signal. Each
    was followed by a full traction effort demand. It is possible that this indicates that
    the driver was having difficulty in accurately controlling the train’s speed. RAIB
    found evidence that other drivers of trains that included Ecofret 2 wagons had
    experienced difficulty like this, especially when attempting to control their train at
    low speed.
135 The double brake application was made shortly after the last of these full traction
    effort demands, and OTDR analysis shows that wagon 12 was approaching the
    point of derailment as the brakes were then releasing (paragraph 37). Baseline
    simulation and sensitivity studies predicted that the longitudinal compressive
    forces acting on wagon 12 would have suddenly reached a maximum at this point
    (appendix C). Sensitivity study C4 predicted the greatest maximum longitudinal
    compressive force, 451 kN (paragraph 92 and figure 19).
136 Further sensitivity studies investigated the significance of the double brake
    application (appendix C) by replacing the associated brake torques in sensitivity
    study C4 with those from:
    • one of the single brake applications made on the approach to LG11 signal
      (sensitivity study C5), where the maximum longitudinal compressive force
      reduced to 125 kN
    • a larger single brake application of approximate equivalence to the double brake
      application (sensitivity study C6), where the maximum longitudinal compressive
      force reduced to 335 kN.
137 The significant force reduction shown in these studies led RAIB to conclude that
    the sudden longitudinal compressive force that caused the derailment was the
    result of the double brake application. Other effects, such as gradient profile, were
    less significant.
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           138 Witness and other evidence indicated a number of possible reasons why the
Analysis
double brake application was made when it was. These were:
               a. Enhanced initial brake applications
                   In May 2021, GBRf issued urgent operating notice UON/21/006 because of
                   technical issues that were believed to concern how the brake distributors fitted
                   to Ecofret 2 wagons interacted with the brake cylinders (appendix E). GBRf
                   had worked with VTG Rail to understand the issues and decide the action
                   needed before issuing this notice.
                   When making an initial brake application, testing had shown that drivers
                   needed to reduce the brake pipe pressure to the lower value of 4.3 bar
                   (instead of a usual 4.6 bar). This was to avoid a reported problem with the
                   brake system venting air on the Ecofret 2 wagons.
                   This became referred to as making an ‘enhanced initial brake application’.
                   Drivers were required to brake in this way when operating any trains that
                   included Ecofret 2 wagons, which meant that it became more difficult to make
                   a long sustained single brake application without the train decelerating too
                   rapidly. Many drivers had found it necessary to adapt their normal driving style,
                   and the need to make a traction effort demand after an enhanced initial brake
                   application was cited as a means of avoiding an unplanned stop. It is possible
                   that the double brake application was an attempt to limit an increase in train
                   speed following a traction effort demand such as this.
               b. Line side lighting
                   The driver regularly operated into London Gateway port (paragraph 31) and
                   reported finding the brightness of the lights located by the port camera and
                   OCR scanner equipment to be a distraction (paragraph 30). Knowing there
                   was a 15 mph (24 km/h) permanent speed restriction shortly after the lights,
                   they might have decided to make the double brake application to reduce
                   the train’s speed in advance, so avoiding the need to make a further brake
                   application as the train passed the lights.
               c. Train mass
                   The driver recalled that train 4L47 felt “heavy” on the journey from Wembley
                   EFOC (paragraph 35). It is possible this influenced their decision regarding
                   the amount of braking force that was required while most of the wagons on the
                   train were still descending the gradient (figure 5).
           Driver guidance and training
           139 Freight train operators are responsible for defining the driving techniques
               they expect their drivers to use and for managing how drivers comply. GBRf’s
               instructions for train operation are defined in a company document called the
               ‘General Operating Appendix’. The document is divided into modules, including:
               • Module A6 – Automatic air brake regulations
               • Module B2 – Professional driving mindset
               • Module B3 – Professional driving skills
               • Module B7 – Economic driving
               • Module B8 – Seasonal risk.
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140 These modules included considerations such as the need to check that the
Analysis
    automatic air brake is functioning correctly (the running brake test, paragraph 34),
    precautions when braking on the approach to signals and other places where it is
    necessary to stop, and the need to anticipate low adhesion conditions. However,
    RAIB found no reference in these modules to a need to drive in a particular
    way with the aim of controlling or limiting train longitudinal forces and shocks.
    Derailment risk mitigation is identified in the modules, but only in the context of
    avoiding excessive speed and operations involving points. GBRf’s manual for the
    class 66 locomotive includes no other driving instructions or guidance relevant to
    the control of longitudinal train dynamic effects.
141 Although not documented in standards or guidance, GBRf explained that brake
    and traction management is covered by instructor feedback during the 225 hours
    of initial training that its drivers need to complete. This includes teaching drivers
    that ‘large shocks’ can result in buffer and coupling damage and failure. However,
    there is nothing similar concerning how train handling effects can also cause
    derailment.
142 GBRf’s employee development system (EDS) includes various routine
    assessments and reviews for managing driving competency after the initial
    training period. GBRf provided a list of the driving-related criteria that are covered.
    Included were topics such as the economic use of the traction controller and
    braking techniques for mitigating the risk of wheel slide. RAIB did not identify any
    criteria relating to derailment risk resulting from the generation of longitudinal
    compressive forces.
143 GBRf operations standards managers (OSMs) routinely review OTDR records as
    part of the EDS process. RAIB asked an OSM from GBRf about the OTDR record
    from train 4L47. They concluded that an OTDR review would not have raised
    undue concern or triggered the need for a support plan or further reviews. It would
    probably have only resulted in constructive feedback about the benefits of braking
    earlier and longer.
Identification of underlying factors
Understanding of derailment risk due to longitudinal compressive force
144 Derailment risks associated with the longitudinal dynamic behaviour of long
    freight trains are not widely understood within the rail industry and there
    are limited supporting processes, tools and knowledge available to assess
    and manage them.
145 Although the rail industry was historically aware of issues such as traction and
    braking effects and buffer interaction, RAIB found that it had undertaken little
    research to further develop its understanding of longitudinal train dynamic
    behaviour and the risk it poses to modern freight train operation (paragraphs
    69 and 71). Longitudinal train dynamics have not been a recurrent factor in
    RAIB freight derailment investigations, and it is probable that derailments of
    this nature have not been occurring as regularly as they once did. This may be
    due to the type of rolling stock now in service and recent operating trends. With
    fewer derailments of this type occurring, it is possible that the need to develop
    understanding in the field has not been considered a priority by the rail industry.
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           146 The derailments involving Ecofret 1 and Ecofret 2 wagons are a reminder that the
Analysis
risks arising from longitudinal compressive forces remain. In addition, the demand
               for shorter intermodal wagons, the increased use of permanently coupled wagons
               with bar couplers in between, and proposals to operate longer and heavier trains
               suggest that such risks may become more significant. The passenger train
               derailment at Neville Hill (paragraph 70) highlights that these risks are not only
               relevant to freight train operation.
           147 The investigation identified four areas where there was a particular lack of
               understanding and supporting resources.
           Derailment resistance assessment
           148 An assessment of rail vehicle derailment resistance requires:
                   • a criterion for quantifying derailment resistance; in this case, for instance,
                     the longitudinal compressive force needed to cause the first wheel to derail
                     (‘full derailment’) or to bring it to position where it is about to derail (‘incipient
                     derailment condition’)
                   • running conditions against which derailment safety is to be assessed; in this
                     case, for instance, the magnitude of the maximum longitudinal compressive
                     force that is considered likely to act.
           149 The parties involved in the development of the Ecofret 2 wagon did not know of a
               standard criterion for assessing the capacity of a triple-wagon to resist derailment
               under longitudinal compressive force (paragraph 112). It was decided to adopt
               an approach that involved the use of the simplified quasi-static simulation model
               to determine the longitudinal compressive force at which the ‘Y/Q derailment
               quotient’31 exceeded a standard critical value of 1.232 (paragraph 111). VTG
               Rail’s engineering consultant had previously looked to validate this approach
               via comparison with the detailed Ecofret 1 triple-wagon computer simulations
               (paragraph 74).
           150 The Y/Q derailment quotient is conventionally used to assess resistance to
               derailment due to flange climbing. In this mechanism, sustained forces need
               to act at the wheel-rail contact point to promote the wheel flange to gradually
               climb onto and over the railhead. The short derailment marks (paragraph 43)
               and supporting wagon derailment simulations (appendix D) showed that the
               mechanism which caused wagon 12 to derail was more complex. It involved
               forces at the wheel-rail interface that acted suddenly, and a sequence of
               intermediate steps, with full derailment probably occurring in a chaotic fashion.
               RAIB is not aware of work to fully validate the ability of standard simulation
               methods to predict full derailment by a mechanism of this complexity, or to
               determine the degree to which earlier steps in the sequence are indicative of an
               incipient derailment condition.
           151 The parties involved were also not aware of a standard that defined the maximum
               longitudinal compressive force likely to act. RSSB was similarly not aware of
               any such standard. VTG Rail’s engineering consultant had instead needed to
               hypothesise a worst-case force (paragraph 81).
31
                The ratio of the lateral (Y) and vertical (Q) forces acting at the wheel-rail contact point.
           32
                As defined in several technical standards, including BS EN14363.
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152 RAIB found evidence of longitudinal compressive force values (termed ‘endurable
Analysis
    longitudinal compressive force’) in the assessment criteria defined in EN15839
    (paragraph 72). However, it was not able to determine the degree to which
    this assessment method was considered relevant to the derailment location
    (paragraph 113). While the Ecofret 2 triple-wagon is a type of wagon that is
    currently out of scope of EN15839, a footnote in the standard explains that
    ‘acceptance conditions’ are being developed for inclusion. At the time of writing
    this report, RAIB has not been able to establish the progress of this work.
153 A suitably developed and robust derailment resistance assessment method would
    have simplified the work undertaken to develop the Ecofret 2 wagon design
    and given greater confidence regarding its ability to resist derailment due to
    longitudinal compressive forces. Such a method may also be applicable to the
    assessment of other wagon types.
Longitudinal train dynamic analysis
154 RAIB found evidence that the parties involved in the development of the
    Ecofret 1 and Ecofret 2 wagons had discussed the idea of a longitudinal train
    dynamics simulation model. This occurred both when they were developing an
    understanding of the early Ecofret 1 triple-wagon derailments and as part of the
    work to obtain authorisation for the Ecofret 2 triple-wagon to enter service. RAIB
    found no evidence of work to develop such a model. This was probably due to a
    lack of knowledge of a suitable existing analysis tool, or due to the complexities
    inherent in developing one.
155 These complexities were illustrated by the work needed to develop the
    longitudinal train dynamic simulation model that was critical to determining and
    understanding the cause of the derailment at London Gateway (paragraph 82b
    and appendix C). This involved the need for fundamental checks to validate
    model behaviour against both basic physical principles and data recorded by the
    locomotive OTDR (paragraph 92). It also involved the need for external expert
    review and advice, including help from those having experience of the longitudinal
    dynamic behaviour of freight trains operating overseas.
156 Certain simulation model parameters required information that could not readily
    be provided. Further validation of the simulation model, for instance, using
    dynamic vehicle testing, was outside of the scope of RAIB’s investigation
    (paragraph 96).
157 A suitably developed and validated simulation model and readily accessible
    parameter information would have helped those developing the Ecofret 2 wagon
    to evaluate the maximum longitudinal compressive force likely to act. Such a
    model would also help operators of long freight trains to assess train configuration
    and operation options designed to limit such forces, and thereby define
    restrictions that should be applied.
158 RAIB is aware of alternative simulation tools that have been developed for
    longitudinal train dynamics analysis.33 It has not assessed the use of these, or
    their limitations and benefits.
33
  For instance, Wu Q et al, ‘International benchmarking of longitudinal train dynamics simulators: results’, Vehicle
System Dynamics, 2018, Vol 56, No 3, 343-365.
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           Train brake force analysis
Analysis
159 RAIB concluded that neither GBRf nor VTG Rail knew of brake testing or other
               data that could be used to help determine the forces acting on the individual
               wagons within the train. The static brake testing undertaken on the two
               representative intermodal trains was the pragmatic means of acquiring the data
               needed to allow RAIB’s investigation to proceed (paragraph 82a and appendix B).
               RSSB had commissioned some potentially relevant laboratory testing in the late
               1990s. However, this was limited and RSSB knew of no other testing that had
               sought to measure brake system pressures on a long freight train or a laboratory
               equivalent.
           160 A literature search undertaken as part of this investigation found reference to the
               use of pneumatic simulation tools for predicting brake pipe and cylinder pressure
               values on long freight trains.34 However, RAIB was not able to find evidence of
               wide-scale rail industry adoption of such tools.
           161 The availability of relevant and reliable brake test data, or a suitably developed
               and validated pneumatic simulation tool of the train air brake system, would have
               helped those developing the Ecofret 2 wagon to assess the brake forces acting
               along the train. This could have been used to help determine the maximum
               longitudinal compressive force likely to act. A pneumatic simulation model
               could be of use to the rail industry in general as it could help operators of long
               freight trains assess options for brake system configuration (such as choice of
               passenger or goods distributor timings) and manage the implications of brake
               system performance issues. It could also be used to inform the development of
               operating standards and restrictions.
           Freight train operation and handling
           162 GBRf had provided no specific guidance to its operating staff on how to manage
               the effects of longitudinal train dynamic behaviour to avoid the risk of derailment
               (paragraphs 140 and 141). RSSB does not publish standards that it would expect
               to be used for this purpose.
           163 The specification of rules and guidance in the relevant train operating standard
               could have reinforced practice that was designed to help control and limit train
               longitudinal forces. As well as driving techniques, such rules and guidance could
               also cover relevant aspects of train preparation, such as the degree to which
               screw couplings need to be tightened (and slack allowed) and any necessary
               restrictions on train consist configuration and loading.
34
              For instance, Catone L, ‘TrainDy: the new Union Internationale de Chemins de Fer software for freight
           interoperability’, Proceedings of the Institution of Mechanical Engineers, Vol 225 Part F: Journal of Rail and Rapid
           Transit.
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Approach to wagon design
Analysis
164 VTG Rail adopted design management arrangements that possibly limited
    its ability to understand the dynamic behaviour of the triple-wagon as
    a complete vehicle system and did not result in it identifying critical
    subsystem performance requirements that were associated with the
    behaviour of the train as a whole.
165 VTG Rail established a steering group to co-ordinate the work of its main
    suppliers (Wabtec and WH Davis) in developing the design of the Ecofret 2
    triple- wagon (the ‘vehicle system’). They worked together using a consortium-type
    project management arrangement, with engineering responsibilities being largely
    divided between these suppliers according to the subsystems within their scope,
    principally the underframe, couplers and bogie (paragraph 51).
166 The responsibilities for evaluating vehicle ride and running safety (largely
    to demonstrate compliance with identified standards (paragraph 62)) were
    separated from those for evaluating derailment resistance under longitudinal
    compressive force (paragraphs 111 and 114 to 116). RAIB found evidence that
    this did not result in use of what would possibly have been the best approach for
    understanding the dynamic behaviour of the vehicle system or the forces relating
    to it.
167 A technical specification was prepared for the wagon, and this effectively defined
    the vehicle and the subsystem requirements. However, the technical specification
    largely cascaded vehicle system requirements to the subsystems according to
    the desired design solution (or feature) rather than on the basis of performance.
    For instance, the bar coupler (part of the coupler subsystem) was specified with
    reference to the supplier’s component drawing, its size (1600 mm long) and its
    design features (incorporation of a ‘rubber damper’).
168 While the ‘draw force’ (the longitudinal tensile force acting on the bar coupler) was
    mentioned as a performance-related requirement, the technical specification was
    silent on the maximum longitudinal compressive force to be catered for. In the
    absence of published values (paragraph 112), efforts to define and validate the
    maximum longitudinal compressive force by consideration of the overall behaviour
    of the train (for instance, by calculation, simulation or test) could have provided
    greater confidence in the derailment resistance of an Ecofret 2 triple-wagon.
169 The division of responsibilities also meant that a computer simulation model
    representing the dynamic behaviour of the complete Ecofret 2 triple-wagon
    was not available. Such a model (like that developed for the wagon derailment
    simulations carried out during the investigation (appendix D)) could have
    provided greater insight into the behaviour of the triple-wagon under longitudinal
    compressive force and the complex interactions of the coupler and bogie
    subsystems. Obtaining approval for the bogie as a separate interoperability
    constituent (paragraph 61) may have reinforced the responsibility division.
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           Data uncertainties and assumptions
Analysis
170 RAIB was mindful that the magnitude of the maximum longitudinal compressive
               forces predicted by the longitudinal train dynamics model were less than that
               calculated as being needed for full derailment by the wagon derailment simulation
               model. This probably arose from data uncertainties and the assumptions that
               were then needed (paragraphs 95 and 96).
           171 Assumptions necessary in the development of the longitudinal train dynamics
               model are probably particularly important in this respect. Several of these related
               to uncertainties associated with effects that could result in greatly increasing
               the magnitude of the predicted maximum longitudinal compressive force. They
               included:
                   a. Coupling tightening and slack
                       The rail industry has long recognised the importance of coupling tightness and
                       slack as a contributor to the generation of longitudinal forces and derailment
                       risk. However, there was a lack of information on the amount of slack within
                       train 4L47. In sensitivity study C1 it was assumed to be zero (appendix C). In
                       sensitivity study C2 a nominal slack of ±25 mm was introduced. This increased
                       the predicted maximum longitudinal compressive force by around 30 kN. The
                       actual amount of slack could have been much greater than this nominal figure
                       and the amount of longitudinal compressive force thereby also greater.
                   b. Coupler friction losses
                       Coupler friction is also recognised as a factor that is important to longitudinal
                       train dynamic behaviour. The only reliable information on this was for the
                       Ecofret 2 wagon coupler components.35 In the baseline simulation, it was
                       assumed that the friction model developed for the Ecofret 2 bar coupler was
                       appropriate to all other couplers on the train (appendix C). Sensitivity study
                       C4 predicted that a 50% reduction in friction, when combined with slack of
                       ±25 mm, increased the longitudinal compressive force by around 130 kN.
                   c. Air brake system equipment
                       It was not possible to use the actual brake pipe and brake cylinder pressures
                       from train 4L47 when determining the wagon brake torque time histories.
                       Measurements from representative trains were instead processed to estimate
                       representative values (appendix B). There was insufficient information
                       to establish the degree to which the air brake system equipment on the
                       representative trains differed in detail from that on train 4L47, for instance,
                       in terms of specification, setting, condition, behaviour, and performance.
                       Sensitivity study C1 showed how the magnitude of the vehicle brake torques
                       could affect the maximum longitudinal compressive force (appendix C). As
                       well as affecting the brake torque magnitude, air brake system equipment
                       differences may have affected the time at which the brake torques applied.
                       Other brake equipment differences, such as the configuration and condition of
                       the mechanical brake rigging, may also have affected the brake torque.
35
                There was some limited information for some components on the FEA wagons.
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        d. Speed dependent braking effects
Analysis
             The double brake application resulted in train 4L47 rapidly slowing. The
             OTDR recorded the locomotive’s speed reducing to less than 9 mph
             (14.4 km/h) before starting to increase as traction was demanded (figure 5).
             The trajectory of the reducing speed suggests that it is possible that wagons
             on the train (whose speed is not recorded by the locomotive’s OTDR), may
             have momentarily been travelling significantly slower. Sensitivity study C4,
             which used the refined traction and brake torque time histories, predicted
             something similar (figure 19). Data published by RSSB suggests that train
             brake forces can rapidly increase at slow speed. This is due to variation in the
             brake block and pad friction characteristic. VTG Rail’s engineering consultant
             hypothesised that this speed dependent effect could as much as double the
             longitudinal compressive force.
        e. Train resistance
             In the absence of experimental or other data, the longitudinal train dynamics
             simulation studies assumed that the train resistance forces would act to slow
             the locomotive and each wagon at the same rate. Deviation from this would
             result in the generation of additional longitudinal compressive (or tensile)
             forces.
        Other uncertainties, such as the lack of information on the characteristics of some
        of the coupler-related components, and the actual mass of the containers, might
        also have affected the accuracy of the calculations.
172 Other assumptions led RAIB to conclude that the baseline wagon derailment
    simulation model probably overpredicted the capacity of wagon 12 to resist
    derailment due to longitudinal compressive force. These principally concerned
    the friction elements used to represent the friction losses in the bar coupler
    (appendices C and D). The formulation of the friction elements meant that their
    line of action remains fixed and does not follow that of the ‘pinlink’ elements they
    are parallel to, which are able to rotate. As a result, the friction-related component
    of the bar coupler force was not accurately aligned. Separate simulation studies
    suggested that this alignment inaccuracy could result in an overprediction of
    resistance of around 100 kN or more. If correct, then this would mean that
    the wagon was more vulnerable in practice to derailment due to longitudinal
    compressive force.
Previous occurrences of a similar character
173 Research published in 200636 reviewed UK railway derailment data for the
    ten- year period between 1992 and 2002. It identified 33 derailment events that
    were due to longitudinal train dynamic effects. Of these, 27 events related to the
    presence of sudden severe longitudinal braking forces. The research identified a
    further four derailments that were due to buffer interaction (referred to as ‘buffer
    locking/forces’).
36
     RSSB report ‘Cost effective reduction of derailment risk: initial analysis’, January 2006. Research project T357.
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           174 The first known derailment of an FWA type wagon due to longitudinal compressive
Analysis
force occurred on 28 August 2015 on the entry line to the north and central rail
               terminals within the Port of Felixstowe. The train comprised a class 66 locomotive
               hauling 31 container flat wagons, which were a mixture of FEA and Ecofret 1
               type wagons. The centre and leading outer wagons of an Ecofret 1 triple-wagon
               derailed, which were the 14th and 15th wagons on the train. Another derailment
               occurred at Peterborough on 17 September 2015. On this occasion, the train
               comprised two class 66 locomotives (one of which was not providing any traction
               effort) and 32 container flat wagons. These were a mixture of FEA and Ecofret 1
               type wagons. The centre and trailing outer wagons of an Ecofret 1 triple-wagon
               derailed. These were also the 14th and 15th wagons on the train. Both trains were
               operated by GBRf.
           175 Both derailments occurred at low speed on straight plain line track. Only the
               leading outer wagon of the Ecofret 1 triple-wagon at Felixstowe was carrying a
               container, while the centre wagon was not loaded in either derailment. The rail
               industry investigation work undertaken in response to these derailments led VTG
               Rail to decide to increase the length of the bar coupler on Ecofret 1 triple-wagons
               (paragraph 76).
           176 The derailment of an empty Ecofret 2 triple-wagon occurred as a result of the
               collision of a GBRf intermodal train at Kisby level crossing on 19 August 2021.
               RAIB has considered the mechanism that caused the wagon to derail as part of
               this investigation (paragraph 79).
           177 The only similar derailment that RAIB has investigated occurred at Neville Hill
               depot on 13 November 2019 (paragraph 70). This involved the collision of a
               relatively new Intercity Express Train. The investigation found that the train
               was susceptible to derailment due to high longitudinal compressive forces.
               This susceptibility was due to the design of the bar coupler arrangement which
               connected the vehicles together. This arrangement allowed the bar coupler to
               rotate relatively freely, and in this regard was like the Ecofret 2 triple-wagon. The
               impact of these features on derailment resistance had not been appreciated when
               the train was designed.
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Summary of conclusions
Summary of conclusions
Immediate cause
178 Longitudinal compressive forces generated within train 4L47 during braking were
    sufficient to cause the wheels on the leading bogie of wagon 12 to suddenly lift
    and run derailed (paragraph 87).
Causal factors
179 The causal factors were:
    a. Wagon 12 was susceptible to derailment under longitudinal compressive force;
       its condition, and the loading of the Ecofret 2 triple-wagon of which it was
       a part, increased this risk (paragraph 99). This causal factor arose due to a
       combination of the following:
          i. The design process for Ecofret 2 wagons did not fully recognise the
             need for there to be a change in design from the Ecofret 1 wagon to
             improve behaviour under longitudinal compressive forces (paragraph 102,
             Recommendation 1).
         ii. It is possible that degradation and wear had resulted in the bogies on
             wagon 12 being in a condition that made the wheel flanges more prone
             to being forced into contact with the rail under longitudinal compressive
             force (paragraph 117, Recommendation 1).
         iii. The way that wagons 11, 12 and 13 were loaded made the wheels of
              wagon 12 more prone to lifting under longitudinal compressive force
              (paragraph 121, Recommendation 1).
    b. The longitudinal compressive forces generated within train 4L47 during
       braking and which acted on wagon 12 were large, significant, and sudden
       (paragraph 125). This causal factor arose due to a combination of the
       following:
          i. Wagon 12 was within a part of the train where the longitudinal
             compressive force generated during braking was likely to be higher than
             at other locations along the length (paragraph 130, Recommendation 2).
         ii. A double brake application, made shortly after passing LG11
             signal, resulted in a sudden and large longitudinal compressive
             force being generated that acted on wagon 12. This coincided with
             wagon 12 approaching the point of derailment (paragraph 133,
             Recommendation 2).
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                         Underlying factors
Summary of conclusions
180 The underlying factors were:
                             a. Derailment risks associated with the longitudinal dynamic behaviour of long
                                freight trains are not widely understood within the rail industry and there are
                                limited supporting processes, tools and knowledge available to assess and
                                manage them (paragraph 144, Recommendation 3).
                             b. VTG Rail adopted design management arrangements that possibly limited
                                its ability to understand the dynamic behaviour of the triple-wagon as a
                                complete vehicle system and did not result in it identifying critical subsystem
                                performance requirements that were associated with the behaviour of the train
                                as a whole (paragraph 164, Learning point 1).
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Actions reported as already taken or in progress relevant to
Actions reported as already taken or in progress relevant to this report
this report
181 Following the Ecofret 2 wagon derailments at Kisby and London Gateway, VTG
    Rail asked its engineering consultant to revisit the earlier quasi-static simulation
    studies (paragraphs 111 and 115). The conclusion drawn from this revised
    simulation was that the derailments were due to the effects of longitudinal
    compressive forces and that a centre wagon payload of more than five tonnes
    greatly increased derailment resistance. As a result, VTG Rail issued temporary
    loading instructions which required the centre wagon of an Ecofret 2 triple-wagon
    to always carry a container, unless both the outer wagons were unloaded. GBRf
    issued urgent operating notice UON/21/007 to ensure loading is undertaken in
    compliance with this instruction.
182 GBRf is assisting VTG Rail to progress modification work to remedy the brake
    distributor issues on Ecofret 2 wagons that had led to GBRf issuing an urgent
    operating notice (paragraph 138a). It is anticipated that this will remove the
    requirement for drivers to make enhanced initial brake applications when
    operating trains that include Ecofret 2 wagons.
183 Wabtec is progressing work to resolve the underlying reasons for the in-service
    degradation of the PLBs on TF20 bogies. It has reported that the bogies on the
    majority of wagons have now been retrofitted with PLBs of a new stronger design.
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                                     Recommendations and learning point
Recommendations and learning point
Recommendations
                                     184 The following recommendations are made:37
1     The intent of this recommendation is to ensure that the vulnerability of
                                                 the Ecofret 2 triple-wagon to derailment due to longitudinal compressive
                                                 forces is fully understood and that the risk of this occurring is
                                                 appropriately controlled.
                                                 VTG Rail, supported by Wabtec UK Ltd, should investigate the dynamic
                                                 behaviour of Ecofret 2 triple-wagons to better understand the operating
                                                 conditions that result in longitudinal compressive forces acting on these
                                                 wagons, their behaviour under such forces, and their capacity to resist
                                                 derailment. This investigation should be used to identify appropriate
                                                 mitigation measures such as design changes and operating restrictions,
                                                 and should specifically include consideration of:
                                                 • improvements to the bar coupler arrangement
                                                 • control of lateral suspension movement
                                                 • wagon payload restrictions
                                                 (paragraphs 179a.i, 179a.ii and 179a.iii).
                                                 This recommendation may also be applicable to other owners
                                                 or operators of rolling stock made up of freight wagons that are
                                                 permanently coupled together using bar couplers at both ends.
37
                                        Those identified in the recommendations have a general and ongoing obligation to comply with health and safety
                                     legislation, and need to take these recommendations into account in ensuring the safety of their employees and
                                     others.
                                     Additionally, for the purposes of regulation 12(1) of the Railways (Accident Investigation and Reporting) Regulations
                                     2005, these recommendations are addressed to the Office of Rail and Road to enable it to carry out its duties under
                                     regulation 12(2) to:
                                     (a) ensure that recommendations are duly considered and where appropriate acted upon; and
                                     (b) report back to RAIB details of any implementation measures, or the reasons why no implementation measures
                                         are being taken.
                                     Copies of both the regulations and the accompanying guidance notes (paragraphs 200 to 203) can be found on
                                     RAIB’s website www.raib.gov.uk.
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                                                                                                Recommendations and learning point
    2    The intent of this recommendation is to ensure that freight trains are
         configured and operated in such a way that the longitudinal compressive
         forces generated in service are not sufficient to cause derailment.
         GB Railfreight, working where appropriate with relevant industry
         working groups, should review the risks associated with longitudinal
         train dynamics when operating freight trains. It should use this to inform
         the development of instructions, best practice guidance and training
         for operations staff so that longitudinal compressive forces are not
         generated that exceed the derailment resistance of the wagons forming
         the train. This work should include consideration of:
          • the management of brake application and traction demands
          • the effects of the train air brake system configuration, setting,
            degradation and operation
          • the control of slack and pre-load in screw coupling and buffer
            arrangements
          • the need for train configuration and payload restrictions and limits
         (paragraphs 179b.i and 179b.ii).
         This recommendation may also be applicable to other freight operating
         companies.
3    The intent of this recommendation is to establish a robust and pragmatic
         industry-wide framework for managing the risks of freight train
         derailments due to longitudinal train dynamic effects.
         RSSB working with the freight operating companies should initiate
         a programme of work to raise the rail industry’s understanding of
         longitudinal compressive forces in freight trains and the associated
         derailment risk. This work should incorporate:
          • identifying, developing and validating analysis tools and techniques
          • determining and validating relevant derailment criteria
          • reviewing and developing a suitable derailment resistance assessment
            process
          • identifying limits for longitudinal compressive force that can be
            generated in operational service, and the practical means by which it
            can be assured that these are not exceeded.
         RSSB should develop a timebound programme for the implementation
         of any appropriate changes identified, such as new or revised standards,
         guidance and operating rules (paragraph 180a).
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                                     Learning point
Recommendations and learning point
185 RAIB has identified the following learning point:38
1     It is important that parties responsible for the introduction of rail vehicle
                                                products and equipment into service, such as new and modified rolling
                                                stock and interoperable components, adopt processes and procedures
                                                which ensure the use of best available engineering design and analysis
                                                practice.
38
                                        ‘Learning points’ are intended to disseminate safety learning that is not covered by a recommendation. They are
                                     included in a report when RAIB wishes to reinforce the importance of compliance with existing safety arrangements
                                     (where RAIB has not identified management issues that justify a recommendation) and the consequences of failing
                                     to do so. They also record good practice and actions already taken by industry bodies that may have a wider
                                     application.
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Appendices
Appendices
Appendix A – Glossary of abbreviations and acronyms
ACS                                           AEGIS Certification Services Limited
ApBo                                                                Approved Body
AsBo                                                             Assessment Body
CCTV                                                       Closed-circuit television
CSM REA           Common Safety Methods for Risk Evaluation and Assessment
DeBo                                                              Designated Body
EDS                                                Employee development system
EFOC                                           European Freight Operating Centre
GB                                                                     Great Britain
GBRf                                                                  GB Railfreight
GSM-R                      Global system for mobile communications - railways
NoBo                                                                  Notified Body
NTR                                                         National Technical Rule
NTSN                                       National Technical Specification Notice
OCR                                                   Optical character recognition
ORR                                                         Office of Rail and Road
OSM                                                 Operations standards manager
OTDR                                                         On-train data recorder
PLB                                                           Primary lateral buffer
RSSB                                              Rail Safety and Standards Board
TSI                                      Technical Specification for Interoperability
VIBT                                              Vehicle inspection and brake test
VTG                             Vereinigte Tanklager und Transportmittel GmbH
WAG TSI                 Technical specification for interoperability relating to the
                                     subsystem ‘rolling stock – freight wagons’
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             Appendix B – Derivation of traction and brake torques
Appendices
B1    In line with normal practice, the locomotive OTDR only recorded the brake
                   pipe and brake cylinder pressures on the locomotive itself (paragraph 36).
                   Although some historical supplementary rail industry data was available, it was
                   not possible to use this to work out the corresponding brake pipe and brake
                   cylinder pressures at each individual wagon.39 RAIB concluded that brake system
                   pressure measurements on a representative train were needed.
             B2    Two intermodal trains were made available on separate dates for brake testing.
                   Each was formed of a class 66 locomotive and a similar number of wagons.
                   Ecofret 2, FEA-A, FEA-B and FEA-C type wagons were included on both trains.
                   Pressure transducers were added to various brake pipe and brake cylinder test
                   points. The driver’s brake valve was operated with the train stationary and the
                   resulting pressure measurements were recorded using a data acquisition unit
                   (figure B1).
Pressure
                                                                                                    transducer
Figure B1: Brake testing arrangements. Inset shows pressure transducer fitted to a test point in the train
             brake pipe. (Main photograph courtesy Railway Braking Associates Limited).
39
                In the late 1990s, RSSB commissioned research that investigated the effect of train length on braking
             distance. Supporting laboratory testing measured the pressures within a single pipe automatic air brake system
             at various train length positions. However, the work was focused on brake application and did not include
             measurements relating to brake release which were also needed.
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B3     This testing had two main objectives:
Appendices
      • To obtain pressure measurements to help characterise the behaviour of the
        various wagon brake equipment types on train 4L47. The first train was mainly
        used for these tests.
      • To simulate the brake applications made by the driver of train 4L47 on the
        Down Thames Haven line and record the corresponding brake pipe and brake
        cylinder pressures at selected positions along the train: the locomotive; the
        first wagon; the 33rd wagon (the location of the last wagon on train 4L47); and
        nominated wagons in between. The second train was used for these tests.
B4     The wagon brake equipment included ‘load weigh valves’ which are used to vary
       the brake cylinder pressure (and therefore the wagon brake force) according to
       wagon suspension displacement (which is proportional to the wagon payload).
B5     Many of the wagons on the tested trains carried no container payload, whereas
       nearly all the wagons on train 4L47 were laden (table 1). As a means of
       accounting for this, the load weigh valves on the wagons of the second train were
       manually configured to behave as though a full container load was being carried.
B6     RAIB used the test data, the locomotive’s OTDR record (figure 5), and a
       combination of brake system design and parameter information to estimate:
      • the magnitude of brake torque acting on the wheelsets40 of each wagon of train
        4L47
      • how this varied in time as the train travelled from Thames Haven Junction to
        where it came to rest.
       This is referred to in the report as the ‘wagon brake torque time history’.
B7     RAIB used a combination of locomotive design and test data to estimate the
       brake torque time history for the locomotive (‘locomotive brake torque time
       history’).41 For this it was able to use the brake pipe and brake cylinder pressures
       recorded by the locomotive’s OTDR directly (paragraph B1). It estimated the
       traction torques acting to accelerate the train (‘locomotive traction torque time
       history’) in a similar way.
B8     When aggregated, the individual torque time histories define how the traction and
       brake forces distribute along the train and vary with time.
40
  The wagons in the longitudinal train dynamics model were represented as having only two wheelsets, whereas
each wagon in train 4L47 had four (see appendix C). Therefore, the brake torques were calculated for each pair of
wheelsets.
41
  The locomotive in the longitudinal train dynamics model was represented as having only two wheelsets,
whereas a class 66 locomotive has six. Therefore, the brake torques were calculated for a set of three wheelsets.
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             Appendix C – Simulation of longitudinal train dynamics
Appendices
C1        In work arising from the investigation of the early Ecofret 1 triple-wagon
                       derailments, it had been necessary to make some significant assumptions and
                       simplifications when hypothesising a worst case longitudinal compressive force
                       (paragraph 81). RAIB concluded that a longitudinal train dynamics simulation
                       model was needed to assess and understand these forces and how they varied.
                       With no pre-existing analysis available, the development of a simulation model
                       was required. For train 4L47, this needed to take into consideration:
                   • the inertia properties of the locomotive and each of the 33 wagons
                   • the characteristics of the couplers connecting the locomotive and wagons
                   • the gradient
                   • the traction and braking forces.
             C2        A simulation model was developed using the longitudinal analysis capabilities of
                       an industry-standard railway vehicle dynamics analysis package. The train was
                       modelled as a string of 34 mass elements connected using pairs of special spring
                       elements (‘bumpstop’ elements) to represent the coupler non-linear stiffness,
                       with friction elements added in parallel to represent the energy absorbing
                       characteristics. The mass elements represented the inertia properties of the
                       non-rotating parts of each of the vehicles. Separate ‘wheelset’ elements, two per
                       vehicle for simplicity, were used to represent the rotating parts (figure C1).
8            7         6        5        4          3             2         1        Locomotive
18       17       16        15        14            13        12       11    10             9
26           25            24            23             22            21        20         19
33            32         31            30       29    28             27
Wagon 13                         Wagon 12                         Wagon 11
                                          Mass element
Brake torque                    Non-linear stiffness element           Wheelset element
Figure C1: Longitudinal train dynamics simulation – model of train 4L47.
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C3     The gradient profile of the Down Thames Haven line was defined in a separate
Appendices
       track model.42 Simulations of train 4L47 running along the line involved defining
       a starting speed and the traction and brake torques acting on the wheelset
       elements to accelerate and decelerate the train as it progressed, step by step.
C4     Data of sufficient integrity was available for most of the model elements.
       However, there was some information that not could not easily be sourced.
       Table C1 summarises the main assumptions that were adopted for the baseline
       simulation case.
Assumption adopted
          Information deficiency
                                                                      - baseline simulation case
 Lack of design and test data for the bar                Parameter data for components of the same
 coupler, screw coupling and side buffer                 generic type used
 arrangements on some of the FEA wagon
 types
 Characteristics of the screw coupling and               Parameter data for components of the same
 side buffer arrangements on locomotive                  generic type used
 66779
 Lack of data on the degree to which screw               Parameters for all side buffer and screw
 couplings were tightened and the resulting              coupling arrangements based on the buffer
 slack or additional preload (paragraphs 56              faces just touching (no slack or additional
 and 57)                                                 preload)
 General lack of data on coupler                         Generic friction model developed and
 friction (and other energy absorption)                  validated for a coupler for which standard test
 characteristics likely in service                       data was available (the Ecofret 2 bar coupler
                                                         arrangement). The same friction model was
                                                         then used for all other couplers.
                                                         In the generic friction model, the force in the
                                                         friction elements (friction force) was equal
                                                         to 50% of the force in the corresponding
                                                         bumpstop element
Table C1: Parameter assumptions adopted for the longitudinal train dynamics baseline simulation case.
C5     In the baseline simulation, the locomotive traction torque, locomotive
       brake torque and wagon brake torque time histories were used as derived
       (appendix B). It predicted a train speed profile that favourably matched
       that recorded by the locomotive OTDR. It also predicted that the maximum
       compressive force in the bar couplers on wagon 12 (that is to say, the
       longitudinal compressive force acting on wagon 12) occurred as the double
       brake application was releasing (paragraph 37). This coincided with the time
       that wagon 12 would have been approaching the point of derailment (figure C2).
       The maximum longitudinal compressive force was calculated to be 203 kN and it
       had rapidly increased to this value. Other longitudinal compressive force peaks
       coincided with brake application events.
42
   Two kilometres of track, level for one kilometre then an uphill constant gradient for another kilometre, were
added ahead of Thames Haven Junction. This was to ensure that the locomotive and all wagons were subject to
the same gradient effects before the train reached the junction and the traction and braking torques were applied.
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Appendices
Speed profile (m/s)
Predicted speed
                                       OTDR speed
                                       Track elevation
                                       Locomotive traction
                                       and brake torque
Wagon 12 (leading bogie)
                                       Wagon 12 brake torque
at point of derailment
                                                               Thames Haven Junction
             Coupler force (kN)
Maximum longitudinal
                                       Coupler force                                        compressive force =
                                       wagon 11 to 12                                             203 kN
                                       Coupler force
                                       wagon 12 to 13
Figure C2: Predicted speed profile and coupler force – baseline simulation. The upper graph plot shows
             the predicted speed profile and that recorded by the locomotive OTDR. The track gradient profile and
             applied traction and brake torques (at the locomotive and wagon 12) are shown for pictorial reference
             only. The lower graph plot shows the predicted variation of the force in the couplers at either end of
             wagon 12.
C6                    Several steps and assumptions were involved in estimating the traction and
                                   brake torque time histories and, because of this, a degree of uncertainly must
                                   be recognised in the results. RAIB found that an improved speed match could
                                   be obtained by factoring the traction and brake torque values (referred to as the
                                   ‘refined traction and brake torque time histories’). No change was made to the
                                   time at which the torques applied. Simulations using the refined traction and
                                   brake time histories are referred to as sensitivity study C1. They predicted the
                                   maximum longitudinal compressive force occurred at the same location, but its
                                   magnitude was greatly increased.
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C7   Other sensitivity studies investigated the significance of the following on the
Appendices
     magnitude and location of the maximum longitudinal compressive force acting on
     wagon 12:
     • coupler slack (sensitivity study C2)
     • coupler friction (sensitivity study C3)
     • coupler slack and friction (sensitivity study C4)
     • the double brake application that was made before the derailment (sensitivity
       studies C5 and C6).
C8   Table C2 summarises each of the sensitivity studies and the magnitude and
     location of the predicted maximum longitudinal compressive force event.
Sensitivity               Description                   Predicted maximum longitudinal
   study                                                        compressive force
                                                      Magnitude            Location
               Baseline simulation                    203 kN      Coincident with leading
                                                                  bogie of wagon 12
                                                                  passing over the point of
                                                                  derailment
     C1        Refined traction and brake torque      322 kN      Coincident with leading
               time histories (paragraph 92)                      bogie of wagon 12
                                                                  passing over the point of
               Other parameters as baseline
                                                                  derailment
               simulation
     C2        ±25 mm slack at all couplers           353 kN      Coincident with leading
               comprising screw coupling and side                 bogie of wagon 12
               buffer arrangements                                passing over the point of
                                                                  derailment
               Other parameters as sensitivity
               study C1
     C3        Friction force equal to 25% of the     324 kN      Coincident with leading
               force in the bumpstop element at all               bogie of wagon 12
               couplers                                           passing over the point of
                                                                  derailment
               Other parameters as sensitivity
               study C1
     C4        ±25 mm slack at all couplers           451 kN      Coincident with leading
               comprising screw coupling and side                 bogie of wagon 12
               buffer arrangements; and friction                  passing over the point of
               force equal to 25% of the force                    derailment
               in the bumpstop element at all
               intervehicle connections
               Other parameters as sensitivity
               study C1
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Appendices
Sensitivity                 Description                       Predicted maximum longitudinal
                study                                                              compressive force
                                                                        Magnitude                Location
                  C5        Brake torques associated with a            125 kN         Coincident with
                            single brake application instead of                       replacement single brake
                            the double brake application.                             application
                            Brake torques for the replacement
                            single brake application equivalent
                            to that of a single brake application
                            made earlier on the Down Thames
                            Haven line.
                            Other parameters as sensitivity
                            study C4
                  C6        Brake torques associated with a            325 kN         Coincident with
                            single brake application instead of                       replacement single brake
                            the double brake application.                             application
                            Brake torques for the replacement
                            single brake application increased
                            to match the approximate overall
                            magnitude of the double brake
                            application.
                            Other parameters as sensitivity
                            study C4
             Table C2: Sensitivity studies – summary and results. Baseline simulation results are included for
             reference.
C9    In summary:
                   • Sensitivity study C1 showed how refinement of the traction and brake torques
                     resulted in greatly increasing the magnitude of the maximum longitudinal
                     compressive force, without altering its location and, therefore, its significance
                     to the derailment. The calculated speed profile closely followed the speed
                     recorded by the locomotive’s OTDR up to where the double brake application
                     started to release. At this location the predicted speed continued to reduce,
                     initially following the trajectory recorded by the locomotive OTDR, but reaching
                     a lower minimum value before rising again.
                   • Sensitivity studies C2, C3 and C4 showed how changing the coupler
                     characteristics could also greatly increase the magnitude of the maximum
                     longitudinal compressive force, again without altering its location on the line.
                     The speed profile calculated in all three studies was nearly identical to that
                     calculated in sensitivity study C1.
                   • The greatest maximum longitudinal compressive force was calculated for
                     sensitivity study C4. Sensitivity studies C5 and C6 showed how making an
                     alternative brake application could have reduced the magnitude of this force.
             C10 Figure 19 shows the predicted speed profile for sensitivity study C4 and the
                 predicted variation of the force in the couplers at either end of wagon 12.
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Appendix D – Wagon derailment simulations
Appendices
D1   RAIB concluded that a new wagon derailment simulation study was needed to
     understand the longitudinal compressive forces likely to present a derailment
     risk to wagon 12. The bar coupler and bogie changes (paragraphs 49 and
     76) introduced to the Ecofret 2 design meant that it was not possible to
     reuse analysis from the earlier Ecofret 1 triple-wagon derailment studies
     (paragraph 74).
D2   Wabtec constructed a vehicle model of the Ecofret 2 triple-wagon that derailed
     using the single-vehicle computer models that it had already developed and
     validated (paragraph 62). RAIB provided the design information for the bar
     coupler components, as supplied by VTG Rail, and the details of the container
     payload, as recorded on the train document (table 1).
D3   ‘Pinlink’ elements were needed to represent the behaviour of the bar couplers
     connecting the wagons to each other. These are special rod-like elements
     that can rotate freely about their end pivot points, and transfer axial forces.
     The location and movement of the pivot points (on the connected vehicle
     underframes) determine the element length and the line of action of the axial
     force. A pinlink element can suddenly rotate (buckle) if the applied compressive
     force becomes too great. This is an important characteristic of the element since
     it means the resulting rapid change in the direction of the axial force, and how it
     acts on the connected underframes, is represented.
D4   The non-linear stiffness characteristic of the two spring units in the bar coupler
     arrangement (figure 11) were defined by reference to supplied test information.
     The friction losses in the bar coupler were represented using a friction model
     like the one adopted in the longitudinal train dynamics simulation model
     (appendix C). The containers on wagons 11 and 13 were represented as
     separate mass elements, tied to the wagon underframe at the spigot locations.
D5   RAIB adjusted the model that Wabtec supplied. For the baseline simulation case,
     this included:
     • Introducing nominal lateral drawbar pivot offsets; VTG Rail’s engineering
       consultant (paragraph 76) had found that such offsets can be significant to
       initiating the behaviour found to occur during such derailments; the value
       chosen (±10 mm) was within what could easily be explained due to the
       general build and maintenance tolerances and possible relative positioning of
       wheelsets on the track.
     • Altering the mass properties of the containers on wagons 11 and 13 to reflect
       measurements made after the derailment (table 1); the heights of each of the
       drawbar pivots were corrected to account for the corresponding change in
       suspension deflection.
     • Altering the stiffness characteristics of the PLBs to account for degradation
       (paragraph 68).
D6   Track geometry recordings from 13 July 2021 (paragraph 29) and wheel profile
     measurements (paragraph 65) were used to create the required track irregularity
     and wheel-rail contact definitions.
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             D7    The baseline simulation study focused on the effect of rapidly applying a
Appendices
sustained longitudinal compressive force on wagon 12 as the Ecofret 2
                   triple- wagon approached the derailment location. This was achieved by defining
                   equal and opposite longitudinal forces that acted on wagon 11 and wagon 13
                   and increasing these in 10 kN steps. The same approach had been used by VTG
                   Rail’s vehicle dynamics specialist in the earlier Ecofret 1 triple-wagon derailment
                   studies. The baseline simulations predicted a derailment sequence that was
                   similar to that described for the earlier Ecofret 1 studies (paragraphs 90 and 91);
                   with reference to figure 18, the following longitudinal compressive forces were
                   required:
                  • 460 kN for the wheel flanges on both bogies of wagon 12 to contact opposite
                    rails (stage C)
                  • 600 kN: for a non-contacting wheel to start lifting off the rail (stage D)
                  • 650 kN: for full derailment (stage E).
             D8    Sensitivity studies investigated the significance of the following on the
                   longitudinal compressive forces required:
                  • PLB condition (sensitivity study D1)
                  • wheel profile condition (sensitivity study D2)
                  • wagon payload (sensitivity studies D3 and D4).
             D9    Table D1 summarises each of the sensitivity studies and the required longitudinal
                   compressive forces that were predicted.
Sensitivity                 Description                     Predicted longitudinal compressive
               study                                                                force required
                                                                          Stage C         Stage D       Stage E
                                                                           Wheel        Non-        Full
                                                                         flanges in   contacting derailment
                                                                        contact with wheel starts
                                                                       opposite rails   to lift
                           Baseline simulation                         460 kN          600 kN         650 kN
                  D1       PLBs intact                                 500 kN          600 kN         680 kN
                           Other parameters as baseline simulation
                  D2       Wheel profiles in accordance with           440 kN          600 kN         640 kN
                           specified P8 wheel profile
                           Other parameters as baseline simulation
                  D3       Container payload of 4.4 tonnes on          540 kN          790 kN         930 kN
                           wagon 12
                           Other parameters as baseline simulation
                  D4       No container payload on wagon 11, 12        510 kN          740 kN         850 kN
                           or 13
                           Other parameters as baseline simulation
             Table D1: Wagon derailment simulations. Sensitivity studies – summary and results. Baseline simulation
             results are included for reference.
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Appendix E – Urgent operating notice concerning trains with Ecofret
Appendices
2 wagons
UON/21/006
URGENT OPERATING NOTICE
         Ecofret2 Wagons –Technical Issues
         Summary
         Following reports of braking technical issues from Train Managers operating trains
         with the new Ecofret2 wagons. GBRf have completed some static testing of these
         vehicles at Peterborough and also dynamic testing with an independent Brake
         Specialist riding GBRf trains with Ecofret2 wagons in the consist.
         The static testing identified an issue during the initial brake application with the
         vehicles in a ‘tare’ condition. However, tests found that if the brake pipe is reduced to
         4.3bar, instead of 4.6bar, then an ‘Initial’ brake application in ’tare’ would occur.
         GBRf are waiting for VTG to confirm the reason behind this issue and proposed
         engineering solution, but believes this is down to how the control side of the brakes
         (manufactured by Dako) interacts with the brake cylinders (manufactured by Wabtec
         Faiveley).
         It has also been noted that the Dako supplied regulator has been occasionally
         venting air continuously following brake applications between 5.0bar & 4.5bar
         (reference ‘Air Flow’ fluctuations). GBRf have failed to repeat this issue on static
         testing, but the loss of air was quite obviously occurring on trains containing Ecofret2
         wagons. The problem was reported to be alleviated by making a more substantial
         brake application of around 4.3bar.
         This affects vehicles starting with the following number range: FWA C
         704520xxxx (end platforms) and 704521xxxx (centre platforms).
         Action Required
         Therefore whilst operating an intermodal services which have Ecofret2 wagons within
         the consist, see number range above, the following applies:
                in order to facilitate an initial brake application drivers MUST reduce the Brake
                 Pipe Pressure to 4.3 Bar. (this includes when required to carry out a Train
                 Manager only brake continuity test), and
                If any unusual fluctuations of the Air Flow gauge are experienced, this should be
                 rectified by use of applying ‘Overcharge’ in the first instance. If this fails to
                 stabilise the fluctuation, the train should be inspected in line with existing
                 operating procedures.
         NOTE: This issue does NOT affect the vehicles ability to develop
         its full brake force potential.
    Issued by:
    GBRf Standards & Training Dept.                  1 of 1                              May 2021
Report 14/2023                                       71                                   December 2023
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Report 14/2023                    72                     December 2023
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This report is published by the Rail Accident Investigation Branch,
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