Where was the location of the incident?

Note: All mention of SPAD in this form refers to provisional SPAD. PART 1 INCIDENT DETAIL 1.1 1.2 What was the date of the incident? (dd/mm/yy) What was the time of the incident? (24 hour clock) 1.3 Where was the location of the incident? 1.4 1.5 1.6 1.7 1.8 1.9 1.10 What was the number of the signal involved in the incident? What is the Engineers Line Reference (ELR) for the location of the incident? What is the type of site? Did the event occur on Network Rail controlled infrastructure? What type of movement was the train undertaking at the time of the incident? Which type of line blockage or possession was involved? What were the weather conditions at the time and location of the incident? Station Track or trackside Level Crossing Tunnel Yard/Depot/Siding Entering a possession Exiting a possession Within a possession None of the above T-COD Disconnection Handsignaller Emergency protection Not in possession Token/block indicator Bright sunlight Dull/Overcast Fair/Fine Rain Falling snow Freezing Frost High wind Mist Thick fog 1.11 Was the visibility at the time and location of the incident More than 200 yards? Less than 200 yards? 1.12 Was frost present? 1.13 Was the site inspected? Page 1 of 10

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: Page 2 of 10

PART 3 SPAD details 3.1 What was the length of overrun? (In metres or yards) 3.2 Did the SPAD occur on a running line? Was the route set from a siding onto a 3.3 running line? Did the train proceed beyond or obstruct 3.4 the fouling point? Was the aspect displayed in sufficient time 3.5 for it to be possible for the driver to stop? Was the line protected by Automatic Train 3.6 Protection (ATP)? 3.7 Was the ATP fully operational? 3.8 Had the ATP been isolated /over-ridden by the driver? (Note : Information to support the answer to this question may be in form RT/3119/B section 4.8) Was the clearing point of a home signal 3.9 exceeded? 3.10 Were there any points run through? Was a braking problem a possible factor of 3.11 the incident? Was low railhead adhesion a possible 3.12 factor of the incident? Was there any damage caused to the 3.13 infrastructure or to the rolling stock? Were there any injuries, excluding traumatic 3.14 shock? 3.15 If 'Yes' to 3.14, were there any fatalities? 3.16 3.17 3.18 3.19 Did the train start from stationary against the signal? Was a conflicting route set ahead of the SPAD? Was the section ahead occupied by another train? Is there a Level Crossing in the route ahead of the SPAD? No Yes, at a platform Yes, NOT at a platform Page 3 of 10

PART 4 SPAD SIGNAL 4.1 4.2 4.3 4.4 4.5 What is the number of the signal passed at danger? eg KX325. Do not leave a space between letters and numbers or use a full stop. What is the type of signal control? What kind of signal is it? Is the SPAD signal controlled by Network Rail? What is the name of the controlling signal box for the SPAD signal? Controlled Automatic Semi-automatic Intermediate block Fixed Four aspect colour light Three aspect colour light Two aspect colour light Fixed colour light Semaphore Disc Position light Subsidiary semaphore Distant semaphore Fixed distant Fixed stop Repeater Limit of shunt (position light type) Two aspect colour light (LED) Three aspect colour light (LED) Four aspect colour light(led) SDO 2 Aspect SDO 3 Aspect SDO 4 Aspect Single lens LED Limit of shunt (Board type) Stop board Handsignal Limit of electrification Marker boards Possession marker boards Points indicator SPAD indicator Closed marker (CTRL use only) Page 4 of 10

PART 4 SPAD SIGNAL - Continued 4.6 4.7 4.8 4.9 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 Indicate if the signal is fitted with any of the following and, if so, the status of the system. Tick all applicable. Not Fitted Fitted and Fitted and not Exempt working working AWS ATP TPWS Mechanical train INDUSI OTHER What was the aspect of the signal at the time of the SPAD? Was the signal equipped with any of the following? Tick all applicable. Do drivers normally encounter this signal at danger? What was the length of the overlap in use of the SPAD signal, at the time of the incident? (yards/metres) Are there any points / switches between the SPAD signal and the next signal? What is the distance to the fouling point from the SPAD signal? (yards/metres) What is the distance from the previous signal? (yards/metres) What date was the SPAD signal last considered by a signal sighting committee? (if known) Is the SPAD signal equipped with approach release for the intended route? Is the SPAD signal preceded by a banner repeater? Is the SPAD signal provided with countdown markers? Is the SPAD signal provided with a SPAD indicator? Is the SPAD signal a semaphore? If so describe its role (eg home, section, junction etc). Red / Stop No light Junction Indicator Position Light Route Indicator Page 5 of 10

PART 5 SIGNAL IN REAR OF SPAD SIGNAL 5.1 5.2 5.3 5.4 5.5 5.6 What is the number of the signal in rear of the signal passed at danger? Eg KX325. Do not leave space between letters and numbers or use full stop. What is the type of signal control? What kind of signal is it? Controlled Automatic Semi-automatic Intermediate block Fixed Four aspect colour light Three aspect colour light Two aspect colour light Fixed colour light Semaphore Disc Position light Subsidiary semaphore Distant semaphore Fixed distant Fixed stop Repeater Limit of shunt (position light type) Two aspect colour light (LED) Three aspect colour light (LED) Four aspect colour light(led) SDO 2 Aspect SDO 3 Aspect SDO 4 Aspect Single lens LED Limit of shunt (Board type) Stop board Handsignal Limit of electrification Marker boards Possession marker boards Points indicator SPAD Indicator Closed marker (CTRL use only) Is the SPAD signal controlled by Network Rail? What is the name of the controlling signal box for the SPAD signal? Indicate if the signal is fitted with any of the following and, if so, the status of the system. Tick all applicable. Not Fitted Fitted and working Fitted and not Exempt working AWS ATP TPWS Mechanical train INDUSI OTHER Page 6 of 10

PART 5 SIGNAL IN REAR OF SPAD SIGNAL Continued 5.7 5.8 5.9 Was the signal in rear of the SPAD signal displaying the correct sequential aspect? If answering no to 5.7, what aspect was the signal in rear of the SPAD displaying? Is the signal in rear of the SPAD signal a semaphore? If so, describe its role (eg home, section, junction etc). Red / Stop No light PART 6 DETAILS OF THE LINE ON WHICH THE SPAD OCCURRED Note: If further lines are involved, complete this section for each additional line and attach to form. 6.1 6.2 What is the type of line? What is the line designation? What is the line name as it appears in the 6.3 Sectional Appendix? (eg Windsor reversible, Up main fast) 6.4 Is the line freight only? 6.5 Did the SPAD occur at a platform? 6.6 What was the aspect of the signal at the time of the SPAD? Running Line Siding Down Up Bi-directional Reversible Single Not applicable - siding Red / Stop Green / Off Yellow Double yellow Flashing yellow No light Alternating Flashing double yellow Page 7 of 10

PART 6 - DETAILS OF LINE ON WHICH THE SPAD OCCURRED- Continued 6.7 Had the rails been treated recently by any of the following? Sandite Waterjet Weedkiller None 6.8 Is the line area prone to leaf fall? Is the line area a known site of low 6.9 adhesion? 6.10 6.11 6.12 6.13 Was one of the following special workings in place at the time of the SPAD? What is the system of signalling of the line in which the SPAD is situated? What is the type of signalling control point? What is the line gradient at the SPAD signal? 6.14 If rising or falling, state the gradient? 1 in Temporary block working Single line working Working by Pilotman None Modified working TCB Absolute block Electric token No signalman token Tokenless block RETB No signalling system Permissive Depot working One train working no staff One train working with staff Power signal box Mechanical signal box Level Falling Rising Page 8 of 10

PART 7 ADDITIONAL INFORMATION RELATING TO THE SPAD INCIDENT 7.1 Please use this space to record any further information relevant to the SPAD incident (please state clearly below if there is no further information to be recorded and why). Page 9 of 10

PART 8 Investigating Officer(s) 8.1 Infrastructure Manager Name: Date form completed: Company: Position: Location: 8.2 Railway undertaking Name: Date form completed: Company: Position: Location: Form Ends If you have difficulty entering data into this form, please contact enquiries@rssb.co.uk Page 10 of 10