RT3185 - RSSB

1 REPORTING A SIGNAL/AWS/TPWS/ERTMS/ATP/TVMFAILURE OR IRREGULARITYFor use by Drivers in allcases of Signal, AWS, ERTMS or TPWS Irregularities and Signallers when the following is reported:- A wrong side signalling failure, an alleged wrong side signalling failure, a signal irregularity which is required to be reported immediately by the Driver in accordance with module S7 andmodule PoSA unless the fault is clearly right side or the Signaller is aware of the circumstances andcan explain the failure or irregularity, Rule Book module TW5 and local ATP/TVM 1 General Information(To be completed in all circumstances)

2 Drivers detailsSignallers detailsDriver reports circumstancesDetails of the train involvedDetails of the rolling stock involvedTick appropriate boxTick appropriate boxSignallerestablishes whether the signalhas been passed at of (d/m/y) (hh:mm) depotReported (Name of Signal Box)(hh:mm) at location of of Train hrs (Time hh:mm)Traction unit No. in :Signalling irregularityTPWS IrregularityTPWS activationERTMS failure or irregularityApproaching:Signal marker No.. Speed restrictionBuffer Stops at.. on the .. line(location) (Name) Driver have you passed a block marker or signal at Danger?

3 YESNOPART 2 Report of Signal Imperfectly Shown or Not ShownDriverquotes the relevant detail(s) -Tickthe relevant elementDrivergives further details of theirregularity, if necessary1. Signal obscured by foliage/bright sunlight/lineside sign *2. Signal not #Notes: * - delete as required # - give details below.. RT3185 December 2015 (Side 1 of 2)DMI failureSystem failure messageOdometer failure (alarm reported on DMI)Balise inconsistencyInappropriate mode displayed, mode displayed..ERTMS level transition failureAn MA beyond a signal at dangerA signal showing a proceed indication but no MA receivedOther.

4 Driverquotes the relevant detail(s) -Tickthe relevant elementDrivergives further details of theirregularity, if necessary(End of Page 1 of 2)PART 3 Report of ERTMS failure or irregularityUncontrolled When Printed Document comes into force on 05/12/2015 Supersedes Form RT3185 Iss 12-15 on 05/12/2015 PART 4 Report or Irregular Signal AspectPART 5 Report of AWS/TPWS/TVM Irregularity or FailurePART 6 Report of Activation of TPWSPART 7 Other details to be completed by the Driver(may be completed post incident) - please use CAPITAL LETTERS(End of Page 2 of 2)Drivers - this form must be handed in accordance with your company instructionsSignallers - this form must now be sent to Operations ControlDriverquotes the relevant detail(s) - Tickthe appropriate box(es)Drivergives further details of theirregularity, if necessarySpecific details of the irregular sequence1.

5 Signal reverted to a more restrictive aspect #4. Arm/disc between ON and OFF *2. Aspects changed randomly #5. White light instead of Red/Yellow/Green *3. Aspect failed (position light signal)6. Signal showing more than one aspect together #Notes:*- delete as required # - give details below..Did the aspect/indication change on approach?YESNOWere there any trains on adjacent line(s)YESNOD riverquotes the relevant detail(s) -Circle the relevant elementDetails of the post incident isolationsThe following fault code was received:Was AWS isolated as a result of this incident?

6 YESNOWas TPWS isolated as a result of this incident?YESNOW here did the brakes apply?Overspeed Sensor before the signalTrain Stop at a signal applicable to the reverse directionTrain Stop at the signalOverspeed Sensor on the approach to buffer stopsElsewhereOverspeed Sensor before a reduction in permissible speedAt what speed were you approaching the location? .. mph / km/h (delete as appropriate)RequiredIndicationRequiredIn dicationActual IndicationFault CodeActual IndicationFault CodeClearHorn & Bell1 NoneHorn8 Horn instead of Bell2 Bell9 None3 Unable to cancel10 WarningBell & Horn4 Indicator did not change to all black11 Bell instead of Horn5 AWS failed to arm12 Brake without Horn6 AWS failed to disarm13 None7 ATP/TVM failed to arm14 Indicator did not change to Yellow & Black7aATP/TVM failed to disarm15 TPWS failed to activate16 TPWS operated when not required17(this is not a fault if it occurs after cancellingthe AWS indication received when setting)

7 Adriving cab into service)Details of the brake demandGive as much detail as possible -continue on a separate sheet ifnecessaryRT3185 December 2015 (Side 2 of 2)Uncontrolled When Printed Document comes into force on 05/12/2015 Supersedes Form RT3185 Iss 12-15 on 05/12/2015