The formal inquiry was convened under independent chairmanship and included representatives on the panel from the involved parties. As with all such inquiries the panel's task was to establish the immediate and underlying causes of the accident and make recommendations to prevent or reduce the risk of recurrence.

Sequence of events

The road level crossing gates at Elsenham were closed to road traffic for the passage of approaching trains. The adjacent station footpath crossing equipped with wicket gates and miniature red/green pedestrian warning lights (MWLs), were showing red and the associated yodel alarms sounding as the 0950 hrs London Liverpool Street to Cambridge service passed over the crossings to stop at the Down platform. The red light remained illuminated and the yodel alarm continued to sound due to the approach of the 0724 hrs Birmingham New Street to Stansted Airport service which was to pass through the station on the Up Line.

Two girls, aged 13 and 14 years, had just purchased tickets for travel to Cambridge from the booking office located on the Up Platform. They approached the station footpath crossing as the Cambridge train stopped onthe opposite, Down Platform. They opened the Up side wicket gate and walked on to the crossing, and in doing so, were struck by the Stansted train. They were both fatally injured.

Conclusions

Immediate cause

The two girls did not react to the red miniature warning light and yodel alarm, which visually and audibly indicated that it was not safe to open the wicket gate and use the station footpath crossing.

Underlying causes

The ability to open the wicket gates and cross the lines when it was not safe
to do so.

Necessity for Cambridge passengers, not in possession of a ticket, to make a purchase on the Up Platform and then cross to the Down Platform.

Insufficient time allowance by the girls to purchase tickets and board the train to Cambridge.

Possible influence on the girls of misuse of the crossing by other, older users.

Recommendations

The report makes recommendations for improvements in a number of key areas and these are summarised as follows.

Applicable to All Types of Level Crossing

? Initiate with Her Majesty?s Railways Inspectorate/Department for Transport a review of Railway Safety Principles and Guidance to produce crossing guidance, warning and access systems that embrace current human factors knowledge, and provide consistent and compatible systems for all types of crossing. The review should establish reasonably practicable controls and identify the extent of user responsibility.
- Network Rail and RSSB

Applicable to Station Footpath and Station Barrow Crossings

? Commission a quantitative risk assessment at Elsenham and the other 13 station footpath crossings with MWLs to establish reasonably practicable safety system options and controls to minimise the risks to users. The assessment should include a consideration of:
? Implications of closure
? Provision of a footbridge
? Minimising need to cross the tracks
? Securing wicket gates
? Improvements to MWLs
? Audible warnings including train horns
? ?Another train coming? warning
? Signing appropriate to MWL crossings
- Network Rail

? Initiate with the Office of Rail Regulation a review of the station access conditions and/or the new station code to provide clarity on the responsibility for management of station footpath and barrow crossings.
- Network Rail

Specific to Elsenham

? Consult with the community leaders at Elsenham to establish their views on the current level of misuse and the balance between convenience and safety during use of the station footpath crossing. Take cognisance of their views in formulating short and long term plans for the crossing.
- Network Rail

? Consider making permanent the temporary video surveillance at Elsenham station footpath crossing. Initiate appropriate action, including enforcement and associated publicity, to deter misuse of the crossing.
- Network Rail

? Arrange publicity and education to explain to the users of Elsenham station, the options for improving safety at the crossing and their responsibility in promoting proper use of the foot crossing.
- Network Rail

? Review the options for providing ticket issuing facilities on the Down platform at Elsenham station by assessing the practicability of installing a self service ticket machine, or alternatively offering a limited range of tickets for stations towards Cambridge, from the shop by the ramp of the Elsenham Down platform.
- ?one? Railway

Records and Information

? At Elsenham, and elsewhere as appropriate, the reporting arrangements for safety related events recorded in the crossing keepers? occurrence book should be reviewed.
- Network Rail

? Existing or planned risk assessment procedures for footpath crossings at stations should be reviewed to ensure that local factors which motivate crossing misuse are properly taken into account.
- Network Rail

RSSB has issued a full copy of the report to each member of the Railway Group and the other organisations involved in the accident. All recipients of the report need to review the findings and recommendations and take actions where appropriate to address identified deficiencies within their own systems. RSSB will track the industry's response to this