Provisional ERTMS SPAD Data

Collection Form RT3119/D

(Railway Undertakings)

Note 1: All mention of SPAD in this form refers to ‘provisional SPAD’.

Note 2: Use this form for gathering SPAD data on an ‘ERTMS Level 2 without signals’
route.

PART 1 – INCIDENT DETAIL

What was the date of the incident?

1.1 (dd/mm/yy)
     
What was the time of the incident?
1.2 (24 hour clock)
     
1.3 Where was the location of the incident?      
What was the number of the block
1.4 marker or shunt board involved in the      
incident?
Was a release speed indicated and if so
1.5 was it adhered to?
     
Has the driver alleged that signal
1.6 sighting was a contributory factor to the click here
SPAD?
Do drivers normally stop at this block-
1.7 marker?
click here
Initial factors involved in the SPAD. Which of the following may be involved and to what level?
Tick all applicable.
Wholly Implicated Partially Implicated Not Implicated
Driver
1.8 Other Persons
Equipment
Weather / Rail
Contamination

RT3119/D September 2014 (Issue 2)

Page 1 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 2 – SUMMARY OF THE INCIDENT

Please use this space to record a brief description of the SPAD incident.
The information written here will be entered into SMIS:
     

RT3119/D September 2014 (Issue 2)

Page 2 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 3 – THE SPAD TRAIN

What was the train reporting

     
number?
What was the train’s departure
     
time?
3.1
Where was the origin of the train?      
Where was the destination of the      
train?
Parcel train
On-track machine
Passenger HST
ECS HST
Open line inspection and work trains
Passenger electric loco hauled
Passenger diesel loco hauled
What was the type of train involved Passenger steam loco hauled
in the SPAD? ECS electric loco hauled
Tick one. ECS diesel loco hauled
3.2 ECS steam loco hauled
Passenger diesel multiple unit
Passenger electric multiple unit
ECS diesel multiple unit
ECS electric multiple unit
Freight - intermodal
Freight - single commodity
Loco only
Trolleys
On track plant
Approaching station / terminal
Running away
Accelerating
Departing station / terminal
Stationary
Decelerating
Running normal
Running propelling
Coasting
What was the train doing at the time
Propelling wrong direction
3.3 the SPAD occurred?
Running back
Tick one.
Braking
Starting other than from station / terminal
Stopping
Not in running
Not known
Movement in possession
Entering a possession
Leaving a possession
Drawing forward
Was the train Driver Only Operated
3.4 (DOO)?
click here
Was the train driven from an
3.5 authorised cab?
click here

RT3119/D September 2014 (Issue 2)

Page 3 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 3 – THE SPAD TRAIN – continued

Under which railway undertaking’s

3.6 safety certificate was the train being      
operated?
Unit 1     
Unit 2     
What were the unit numbers in the
3.7 train’s composition? Unit 3     
Unit 4     
What was the total number of
3.8 vehicles?      
(inc. locomotive(s))
AFI brake
Air
EP brake / Auto
EP brake auto or normal unknown
EP brake - normal
Hand / Parking
Light locomotive only
One pipe air
What was the type of brake control?
3.9 Tick one.
Seven step
Three step
Two pipe air
Unbraked / Isolated
Vacuum
Westcode
Other
Rheostatic
Regenerative
If a rheostatic brake was fitted, was
3.10 it working?
click here
If a regenerative brake was fitted,
3.11 was it working?
click here
Disc
What was the type of brake gear? Clasp cast iron
3.12 Tick one. Clasp composite
Mixture
Authorised tonnage      
Authorised brake force      
What was the tonnage / brake
3.13 force? (Freight train only) Actual tonnage      
Actual brake force      
Was the correct data (tonnage /
3.14 brake force) entered? (Note: If not, click here
give details and attach to this form).
Was the driver accompanied in the
3.15 driving cab?
click here

RT3119/D September 2014 (Issue 2)

Page 4 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 3 – THE SPAD TRAIN – continued

3.16 If the driver was accompanied in driving Trainee driver

cab, indicate by whom. Shunter
Tick as appropriate. Driver Instructor (or equivalent)
Signaller
Driver Manager (or equivalent)
Guard
Route Conductor
Other      
3.17 What was the total number of persons in      
the cab?

PART 4 – LEADING VEHICLE OF THE SPAD TRAIN

4.1 What was the type of the leading vehicle Road rail vehicle (RRV)
of the SPAD train? Driving van trailer (DVT)
Tick one. Wagon
Multi-purpose vehicle (MPV)
Rail mounted maintenance machines (RMMM)
Other
Loco
Carriage
Power car
Trailer
Unit
Trolley
4.2 What was the class and sub class of the      
vehicle?
4.3 What was the number of the vehicle /      
traction unit from which the train was
being driven?
DMU / EMU trailer vehicle
What was the leading vehicle’s role as Driving traction
4.4 driving traction for the train? Hauled vehicle
Tick one. Other driving vehicle
Other vehicle
4.5 What was the status of the driver Driver set DRA fitted and used
reminder device (DRA)? Driver set DRA fitted but not used
Tick one. Driver set DRA fitted and not working
DRA not fitted
Not applicable
Was the juridical recorder unit (JRU)
4.6 working?
click here
Had ERTMS been isolated by the
4.7 driver? (Note: If yes, give details in click here
section 2).

PART 5 – DRIVER OF THE SPAD TRAIN

What employee type was the driver of Workforce

5.1 the SPAD train? Contractor
Surname:      
Forename(s):      
5.2 What are the driver’s details?
National insurance number:      

RT3119/D September 2014 (Issue 2)

Page 5 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

Was the driver injured as a

consequence of the SPAD?
5.3 If YES, please ensure the respective click here
personal accident form is completed and
attached to this form.
5.4 Who is the driver’s employer?      

5.5 Who is the driver’s manager?      

State the name of the driver’s base
5.6 (depot).
     
Was anyone other than the driver
5.7 implicated in the SPAD?
click here
5.8 Is that person safety critical? click here
5.9 Was the driver authorised to be there? click here
Did the driver experience unusual
5.10 circumstances at the time of the SPAD?
click here
If ‘Yes’ to 5.10, what was the nature of Emergency conditions
5.11 the unusual circumstances? Abnormal conditions
Tick one. Degraded conditions

PART 6 – PERSONAL DETAILS OF THE DRIVER OF THE SPAD TRAIN – Service / Competency /
Fitness

Date of birth      

Date entered service      
Driver’s details:
6.1 Date entered current grade      
(date passed as a driver, not necessarily with
current employer)
6.2 Is formal competency required? click here
What was the date of the driver’s last
6.3 certification?
     
What was the date of driver’s last
6.4 competency assessment?
     
What was the date of driver’s last
6.5 practical assessment (‘in-cab’ or      
similar)?
What was the date of driver’s last
6.6 medical?
     
What was the result of driver’s last
Passed
6.7 medical?
Passed with conditions
Tick one.
Had the driver been taking any self-
6.8 prescribed medical treatments? click here
(If 'Yes' describe below in 6.10)
Had the driver been taking any
6.9 prescribed medical treatments? click here
(If 'Yes' describe below at 6.10)

RT3119/D September 2014 (Issue 2)

Page 6 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 6 – PERSONAL DETAILS OF THE DRIVER OF THE SPAD TRAIN – Service / Competency /
Fitness – continued
Give details of any medical restrictions or conditions imposed following a medical or as a
result of treatments being taken.
     

6.10

Is the driver authorised to wear visual

6.11 aids?
click here
If 'Yes' to 6.11, were the authorised
6.12 visual aids being worn at the time of the click here
SPAD?
Authorised distance visual aids
Unauthorised distance visual aids
What types of visual aids (if any) were Contact lenses
being worn by the driver at the time of Laser eye surgery
6.13 the SPAD? Unauthorised sunglasses
Tick one. Authorised sunglasses
Authorised prescription sunglasses
Other      
Had the driver recently suffered ill-
6.14 health?
click here
If ‘Yes’ to 6.14, what were the dates From      
6.15 between which the ill-health was
To      
suffered?
Give details of the recent ill-health
     

6.16

What was the date of the driver’s last

drugs or alcohol test?
6.17 (Including any test carried out after this
     
accident)
What was the nature of the last test? For cause
6.18 Tick one. Random
What were the test results? Negative
6.19 Tick one. Positive

RT3119/D September 2014 (Issue 2)

Page 7 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 7 – PERSONAL DETAILS OF THE DRIVER OF THE SPAD TRAIN – Duty / Time

Start      
7.1 What were the driver’s rostered hours?
Finish      
Date      
7.2 When was the actual start of the shift?
Time      
Start      
At what time was the driver’s physical
7.3 needs break? Finish      
How many hours had the driver been
7.4 driving prior to the SPAD?
(Hrs undertaking activity)      
Date      
When did the driver’s previous duty
7.5 start? Time      
Date      
When did the driver’s previous duty
7.6 finish? Time      
What was the approximate duration of
7.7 the driver’s last sleep?
(hours)      
How many consecutive days had the
7.8 driver worked prior to the SPAD?
     
How many hours had the driver worked
in the previous 7 days prior to the
7.9 SPAD?      
(Please attach / give details of the
drivers roster for previous 7 days)
What is the usual journey time from the
7.10 driver’s home to the driver’s place of      
employment?
Ordinary (booked diagram)
Duty What duty was the driver working? Rest day / Free day worked
7.11 Tick one. Sunday
Overtime
Other      
7.12 Is this normal activity? click here
Working alone
What was the level of supervision? Working with others supervised
7.13 Tick one. Working under direct supervision
Working with others unsupervised
7.14 Was the activity authorised? click here

RT3119/D September 2014 (Issue 2)

Page 8 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 8 – DRIVER’S DETAILS – Experience

What was the date the driver last signed

8.1 the route?
     
Was this the first time the driver had
8.2 signed the route?
click here
How long has it been since the driver       Weeks
8.3 last worked the route?
      Days
Daily
Monthly
Weekly
How often does the driver work this
8.4 route?
2 monthly
2 weekly
6 monthly
Less frequently

PART 9 – DRIVER’S DETAILS – Driver’s understanding of the incident

9.1 Did the driver allege faulty equipment? click here

Brakes
If ‘Yes’ to 9.1 what type of equipment
Speedometer
9.2 was alleged to be faulty?
DMI
(Please tick all that apply)
Other
Did the driver allege that there were
9.3 other people involved?
click here
Trainee driver
Shunter
Driver Instructor (or equivalent)
If 'Yes’ to 9.3, who? Signaller
9.4 (Please tick all that apply) Driver Manager (or equivalent)
Guard
Route Conductor
Other      
Does the driver admit to having any
9.5 difficulties with this traction unit?
click here
Does the driver perceive this route as
9.6 difficult?
click here
Does the driver perceive the train
9.7 movement(s) being made at the time of click here
the SPAD as difficult?
9.8 Does the driver admit his own error? click here

RT3119/D September 2014 (Issue 2)

Page 9 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 10 – OTHER PERSONS INVOLVED

Note. If more than one person was involved, complete additional sections 10, 11, 12, 13 and 14 for
each person involved and attached to this form.

Surname:      

10.1 Person’s details: Forename(s):      

National Insurance number:      
Passenger
Person on business (train based)
Workforce
Contractor
What is the person’s occupation?
10.2 Tick one.
British Transport Police
On board catering
Other member of public
Railway neighbour
Person on business (not train based)
Was the person injured as a
consequence of the SPAD?
10.3 If YES, please ensure the respective click here
personal accident form(s) is completed
and attached to this form
10.4 Who is the other person’s employer?      
Who is the other person’s local      
10.5 manager?
Train crew (front end)
Train crew (rear end)
Other on board staff
Revenue protection staff
Shunting staff
Platform staff
What is the other person’s occupation (if
Trackside staff
they are a member of the workforce or a
10.6 contractor)?
Signalling / Level Crossing staff
Workshop / Stores staff
Tick one.
Office staff
Other      
Cleaner
On-board catering staff
Train maintenance staff
Depot supervisors / Admin staff
State the name of the person’s base      
10.7 (depot).
Was the person implicated in the
10.8 SPAD? (ie, is the person alleged to be click here
wholly or partly responsible?)
10.9 Is the person safety critical? click here
10.10 Was the person authorised to be there? click here

RT3119/D September 2014 (Issue 2)

Page 10 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 11 – OTHER PERSON’S DETAILS – Service / Competency / Fitness

Please complete this section if the other person is either Workforce or a Contractor

Date of birth      

Date entered service      
Date entered current grade      
11.1 Person’s details:
(Date entered this grade, not necessarily with
current employer)

Date entered current duties      

What job role was being carried out by

     
11.2 the person involved at the time of the
incident?
Is formal competency required for the
11.3 role described in 11.2?
click here

Did the person attain the required

11.4 standard at the last assessment for that click here
role?
What was the date of the person's last      
11.5 certification?
11.6 Is the person’s certificate still valid? click here
What was the date of the person’s initial      
11.7 training (if known)?
Had refresher training been given, and if
11.8 so what was the date (if known)?
     
What was the date of the person's last      
11.9 competence assessment?
What was the date of the person's last
11.10 practical assessment (‘in-cab’ or      
similar)?
What was the date of the person's last      
11.11 medical?
Passed
Failed visual
What was the result of the person’s last
Failed hearing and visual
11.12 medical? Passed with conditions
Tick one.
Failed hearing
Not applicable
Had the person been taking any self-
11.13 prescribed medical treatments? click here
(If ‘Yes’ describe below at 11.15).
Had the person taken any prescribed
11.14 medical treatments? click here
(If ‘Yes’ describe below at 11.15).
Give details of any medical restrictions / conditions imposed following a medical (include
treatments being taken or administered).
     
11.15

RT3119/D September 2014 (Issue 2)

Page 11 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 11 – OTHER PERSON’S DETAILS – Service / Competency / Fitness – continued

Was the person authorised to wear

11.16 distance corrective aids to vision? click here
If 'Yes' to 11.16, were the authorised
11.17 aids to vision worn? click here

Authorised distance aids to vision

Contact lenses
Laser eye surgery
11.18 What aids to vision (if any) were used? Authorised sunglasses
Unauthorised sunglasses
Other
Had the person recently suffered ill-
11.19 health? click here
If ‘Yes’ what were the dates between From      
11.20 which the ill-health was suffered? To      
Give details of the recent ill-health.
     

11.21

What was the date of person’s last drug

or alcohol test?      
11.22 (Including any test carried out after the
accident).
For cause
11.23 What was the nature of the last test? Random
Was the test result negative? Yes
11.24 Tick one. No

RT3119/D September 2014 (Issue 2)

Page 12 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 12 – OTHER PERSON’S DETAILS – Duty / Time

What were the other person’s rostered Start      

12.1 hours? Finish      
Date      
When was the actual start of the other
12.2 person’s shift? Time      
Start      
At what time was the other person’s
12.3 physical needs break? Finish      
How many hours had the other person (Hrs undertaking activity)      
12.4 been driving prior to the SPAD?
Date      
When did the other person’s previous
12.5 duty finish? Time      
What was the duration of the other (hours)      
12.6 person’s last sleep?
How many consecutive days had the
12.7 other person worked prior to the SPAD?
     
How many hours had the other person
12.8 worked in the previous 7 days prior to      
the SPAD?
What is the usual journey time from the
12.9 other person’s home to the other      
person’s place of employment?
How many actual hours of duty had the
other person worked prior to the SPAD?
12.10 (Please attach roster for previous 12      
days including the day the SPAD
occurred).
Ordinary
Booked off
What duty was the other person Other than these     
12.11 working? Overtime
Tick one. Sunday
Emergency call out
Rest day worked
12.12 Is this normal activity? click here
Working alone
Working with others unsupervised
What was the level of supervision?
12.13 Tick one. Working under direct supervision
Supervising others
Working with others supervised
12.14 Was the activity authorised? click here

RT3119/D September 2014 (Issue 2)

Page 13 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 13 – CAUSE – Immediate Cause

 Where the driver or other person is either wholly or partly implicated, complete section 13.1.
A separate report should be made (and attached) for each person, where appropriate.
 Where the immediate cause(s) is established as being due, either wholly or partly, to alleged
failures of or defects in any infrastructure or equipment, a separate report should be made for
each item of infrastructure or equipment, where appropriate.
 The answer to the following questions should be based on the available evidence at the time this
data collection form was completed.
 The lead investigators for the incident should review, revise and confirm the group cause in their
final report.

Tick One
Miscommunication due to wrong information given
Miscommunication due to ambiguous / incomplete information

Group 1
given
Miscommunication due to information not given
Miscommunication due to correct information being given, but
being misunderstood
Not monitoring for a block marker, shunt marker or other indication
of authority
Failure to observe correct Driver Machine Interface (DMI)
indications
Misread DMI indications

Group 2
13.1 Failure to locate correct block marker, shunt marker or other
indication of authority
Anticipation of Movement Authority extending on the DMI
Lack of knowledge of rules / instructions
Violation of rules / instructions
Failure to react to an indication from DMI
Group 3

Group 3 not applicable but kept to align numbering with RT3119/B

form

Misjudged train handling

Group
4

Misjudged environmental conditions

RT3119/D September 2014 (Issue 2)

Page 14 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 14 – CAUSE – Basic / underlying causes

 To be completed in respect of the driver or other person if either wholly or partly implicated. A
separate report should be made for each person, where appropriate.
 To be completed in respect of any infrastructure or equipment, etc if either wholly or partly
implicated. A separate report should be made for each item of infrastructure or equipment, where
appropriate.

Personal Factors

FATIGUE
Was fatigue a possible contributory click here
14.1 factor?
If ‘Yes’ to 14.1, what was the cause / Workload
14.2 nature of the fatigue? Shift / work patterns
Tick as many as appropriate. The individual’s lifestyle
Long working hours
If 14.2 includes ‘Shift/work patterns’, Successive early shifts
14.3 what was the nature of the pattern? Successive night shifts
Inadequate rest breaks
If 14.2 includes ‘Workload’, describe the
Too demanding
14.4 type of work.
Too undemanding
Tick one.

FITNESS
Was the individual's physical fitness a
14.5 possible contributory factor?
click here
Influence of medication / treatment
If ‘Yes’ to 14.5, how might the
Temporary disability
individual's physical fitness have been a
14.6 factor?
Recognised illness
Recent ill-health
Tick as many as appropriate.
Under the influence of drugs / alcohol

COMPETENCE
Was the individual’s competence a
14.7 possible contributory factor?
click here
If ‘Yes’ to 14.7, indicate the area(s) of Training
the individual’s competence that might Experience
14.8 have been contributory. Briefing / Information
Tick as many as appropriate. Assessment
If 14.8 includes ‘Training’, was it
associated with the initial or refresher Initial
14.9 training? Refresher
Tick one.

RT3119/D September 2014 (Issue 2)

Page 15 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)
PART 14 – CAUSE – Basic / underlying causes - continued
COMPETENCE – Continued
If 14.8 includes ‘Training’, what was the
14.10 nature of the training issue?
Tick as many as appropriate.
If 14.8 includes ‘Briefing / Information’,
what was the nature of the briefing
14.11 issue?
Tick as many as appropriate.
If 14.8 includes ‘Assessment’, what was
14.12 the nature of the assessment issue?
Tick as many as appropriate.
If 14.8 includes ‘Experience’, what was
14.13 the nature of the experience issue?
Tick as many as appropriate.
RT3119/D
Page 16 of 23
None provided - Needs not identified
None provided - Inadequate resources
Inadequate - Insufficient opportunity to
practice skills
Inadequate - Not appropriate to job / activity
Inadequate - Substandard instruction /
delivery
Inadequate general safety briefing system
Inadequate urgent advice process
Inadequate work planning
Inadequate hand-over process
Assessment not comprehensive
Inadequate standards for assessment
Inadequate resources for assessment
Task / situation unfamiliar - Lack of training
Over familiar with task - Complacency
Task / situation unfamiliar - Lack of
experience in unusual circumstances
Task / situation unfamiliar - Not normal job /
activity
September 2014 (Issue 2)
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 14 – CAUSE – Basic / underlying causes - continued

ATTENTION
Was ‘Attention’, or lack of it, a possible
14.14 contributory factor? click here
If ‘Yes’ to 14.14, what was the nature of
Reliance
the individual's attention (or possible
14.15 lack of it)?
Preoccupation
Distraction
Tick as many as appropriate.
If 14.15 includes ‘Reliance’, what was Anticipation
the nature of the individual’s Autopilot
14.16 expectation? Other
Tick as many as appropriate.
Home / domestic problems
Work problems
If 14.15 includes ‘Preoccupation’, what
Health problems
14.17 was the nature of this? Morale
Tick as many as appropriate.
Life events
Other
People - Passenger
People - Trespasser
People - Colleague
People - Supervisor / Manager
People - Trackside worker
If 14.15 includes ‘Distraction’, what was
Alarms
14.18 the nature of this? Equipment
Tick as many as appropriate.
Environment / workplace
Work activities
Phone (personal)
Phone (work)
Other

MOTIVATION
Was ‘Motivation’, or lack of it, a possible
14.19 contributory factor? click here
If ‘Yes’ to 14.19, what was the nature of Failure to take account of risks
the individual's motivation (or possible Low morale
14.20 lack of it)? Inappropriate supervision / management
Tick as many as appropriate. Improper incentives

RT3119/D September 2014 (Issue 2)

Page 17 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)
PART 14 – CAUSE – Basic / underlying causes - continued
PROCEDURES
Were ‘Procedures', or their inadequate /
14.21 inappropriate use, a possible
contributory factor?
If ‘Yes’ to 14.21, indicate the nature of
14.22 use / possible misuse.
Tick as many as appropriate.
If ‘Yes’ at 14.21, indicate reasons for
14.23 use / possible misuse.
Tick as many as appropriate.
If 14.23 includes ‘Inadequate
14.24 documentation’, indicate why.
Tick as many as appropriate.
COMMUNICATION
Was ‘Communication', or lack of it, a
14.25 possible contributory factor?
If ‘Yes’ to 14.25, indicate whether this
was during the passing or receiving of
14.26 information.
Tick one or both as appropriate.
If 14.26 includes ‘Passing information',
14.27 indicate how this was a factor.
Tick as many as appropriate.
RT3119/D
Page 18 of 23
click here
Step in procedure missed out
Carried out in wrong sequence
Delay in implementation
Deliberately not followed
Used incorrect or alternative unauthorised
procedure
Inadequate documentation
Misunderstood
Lack of local applicability
Lack of training / briefing
Lack of familiarity with procedure
Conflicting activities / unworkable
Complex / difficult to understand
Inadequate supervision
Inattention
Inadequately planned
Ambiguous / Unclear
Not complete
Not available – Not produced
Out of date
Not available – Not distributed
Not accurate
Too little information
Too much information
Difficult to read
click here
Passing information
Receiving information
Failed to check understanding
Failed to repeat back message
Failed to identify person
Failed to identify location
Failed to take lead responsibility
Inadequate equipment
Other
September 2014 (Issue 2)
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 14 – CAUSE – Basic / underlying causes – continued

COMMUNICATIONS – continued

Failed to check understanding

If 14.26 includes ‘Receiving information',
indicate how this might have been a
14.28 factor.
Tick as many as appropriate.
Failed to repeat back message
Failed to identify person
Failed to identify location
Failed to take lead responsibility
Inadequate equipment
Complex message
Other

WORKLOAD
Was ‘Workload' a possible contributory
14.29 factor? click here
If ‘Yes’, indicate whether it was mental
Mental
14.30 or physical workload, or both. Physical
Tick one or both as appropriate.
Inadequate workload planning - Time
pressures
Tasks undemanding - Monotonous / boring
Inadequate workload planning - Improper
supervision
If ‘Yes’ at 14.29, indicate the nature of
Inadequate workload planning - Insufficient
14.31 the 'Workload' issues. resources
Tick as many as appropriate.
Situational demands - emergency / degraded /
abnormal conditions
Situational demands - High-risk environment
Task undemanding - Repetitive
Other

SUPERVISION
Was ‘Supervision', or lack of it, a
14.32 possible contributory factor? click here
Poor example set by supervisor
If ‘Yes’, indicate the nature of the
Conflicting job / task demands of supervisor
14.33 ‘Supervision' issues.
Inadequate supervisory skills / knowledge /
Tick as many as appropriate.
experience

RT3119/D September 2014 (Issue 2)

Page 19 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 14 – CAUSE – Basic / underlying causes - continued

WORKPLACE
Was a ‘Workplace' issue(s) a possible
14.34 contributory factor? click here
If ‘Yes’, indicate whether the issue(s)
might have been related to
Environmental
14.35 'Environmental' or ‘Design' issues, or
Design
both?
Tick one or both as appropriate.
Lighting
Noise
Vibration
If ‘Environmental' at 14.35, indicate the Temperature
14.36 nature of the issue(s). Humidity
Tick as many as appropriate. Ventilation
Restricted space
Poor housekeeping
Other      
Inadequate visibility - obscured by structure
Inadequate accessibility
Inadequate visibility - obscured by sunlight /
glare / lighting
If ‘Design' at 14.35, indicate the nature
Inappropriate alarms - not visible / audible
14.37 of the issue(s). Inadequate visibility - viewing / sighting time
Tick as many as appropriate.
Inappropriate alarms - not distinct
Inadequate visibility - viewing / sighting time
Inappropriate alarms - not meaningful
Other      

EQUIPMENT
Was an ‘Equipment' issue(s) a possible
14.38 contributory factor? click here
Non rail vehicle
Tool / Equipment
If ‘Yes’, what was the equipment Infrastructure
associated with? Level crossing
14.39 Rail vehicle
Tick as many as appropriate – if more Plant and machinery
than one applies. Communications
PPE
Other      
Supply / Procurement
If ‘Yes’ at 14.38, indicate the possible Condition
14.40 nature of the 'Equipment' issue(s)? Maintenance
Tick as many as appropriate. Usage
Design

RT3119/D September 2014 (Issue 2)

Page 20 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 14 – CAUSE – Basic / Underlying Causes – continued

SUPPLY
If 14.40 includes ‘Supply / Procurement',
14.41 what was the nature of the issue?
Tick as many as appropriate.
Inadequate supply – Inadequate purchasing
Inadequate supply – Inadequate resources
Failure of supplier
Poor work planning
Inadequate supply / Lack of process for
ordering parts / spares / replacements

USAGE
Inappropriate equipment for task
Inadequate procedures for use
If 14.40 includes ‘Usage', what was the Supplied but not used
14.42 nature of the supply issues? Not familiar in its use
Tick as many as appropriate. Used without authority
Inappropriate supervision
Not trained / instructed in use

CONDITION
Inadequate housekeeping
Affected by weather / climate
Inadequate repair
If 14.40 includes ‘Condition', what was
Unreliable
14.43 the nature of the condition issues? Vandalised
Tick as many as appropriate.
Inadequate transportation
Aged
Worn out

MAINTENANCE
If 14.40 includes ‘Maintenance', what Inadequate maintenance specification
was the nature of the maintenance Inadequate inspection / monitoring
14.44 issues? Inadequate planning / scheduling of
Tick as many as appropriate. maintenance

DESIGN
If 14.40 includes ‘Design’, what was the Inadequate design for intended use
14.45 nature of the design issues? Inadequate consideration of ergonomic
Tick as many as appropriate. principles

RT3119/D September 2014 (Issue 2)

Page 21 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 15 – Additional information relating to the SPAD incident

Please use this space to record any further information relevant to the SPAD incident (please
15.1 state clearly below if there is no further information to be recorded and why).     
     

RT3119/D September 2014 (Issue 2)

Page 22 of 23
Provisional ERTMS SPAD Data
Collection Form RT3119/D
(Railway Undertakings)

PART 16 – Investigation Officer(s)

Investigating Officer of railway undertaking / Contractor / Other

Name      
Company      
16.1 Position      
Location      
Date form completed     

Investigating Officer of railway undertaking / Contractor / Other

Name      
Company      
16.2 Position      
Location      
Date form completed     

Network Rail Investigating Officer

Name      
Route      
16.3 Position      
Location      
Date form completed     

Form Ends
If you have difficulty entering data into this form, please contact enquirydesk@rssb.co.uk

RT3119/D September 2014 (Issue 2)

Page 23 of 23