Failure to protect staff
AN INVESTIGATION into the deaths of two rail workers on tracks in south Wales has found that Network Rail failed over many years to protect staff from moving trains.
AN INVESTIGATION into the deaths of two rail workers on tracks in south Wales has found that Network Rail failed over many years to protect staff from moving trains.
Gareth Delbridge, 64, from Kenfig Hill, and Michael “Spike” Lewis, 58, from North Cornelly, were working on the signals at Margam East Junction when they were hit by a passenger train travelling from Swansea to London Paddington. A third worker came very close to being struck.
A report by the Rail Accident Investigation Branch (RAIB) said that Network Rail had been required to make “major changes” to implement “significant” alterations to the standard governing track worker safety, but had not effectively put them in place across its maintenance organisation over a “period of many years”.
Network Rail said it had “fundamentally” changed the way it planned and delivered work since the workers’ deaths.
The three workers, who were part of a group of six staff, were carrying out a maintenance task on a set of points on July 3, 2019.
The driver made an emergency brake application about nine seconds before the accident and continued to sound the train’s horn as it approached the three track workers.
The train was travelling at about 50mph when it struck the men.
Past reports have found that the accident happened because the three track workers were working on a line that was open to traffic, without the presence of formally appointed lookouts to warn them of approaching trains.
They were carrying out a maintenance activity which they did not know to be unnecessary.
All three workers were almost certainly wearing ear defenders, because one of them was using a noisy power tool, and all had become focused on the task they were undertaking. None of them was aware that the train was approaching until it was too late for them to move to a position of safety.
Subsequent acoustic measurements have shown that they would not have been able to hear the train’s warning horn.
The RAIB report found several factors which led to the deaths, relating to the work itself, the way the safe system of work was planned and authorised, the way in which the plan was implemented on site, and the lack of effective challenge by colleagues on site when the safety of the system of work deteriorated.
Four underlying factors were identified:
Over a period of many years, Network Rail had not adequately addressed the protection of track workers from moving trains. The major changes required to fully implement significant changes to the standard governing track worker safety were not effectively implemented across Network
Rail’s maintenance organisation.
Network Rail had focused on technological solutions and new planning processes, but had not adequately taken account of the variety of human and organisational factors that can affect working practices on site.
Network Rail’s safety management assurance system was not effective in identifying the full extent of procedural non-compliance and unsafe working practices, and did not trigger the management actions needed to address them.
Although Network Rail had identified the need to take further actions to address track worker safety, these had not led to substantive change prior to the accident at Margam.
The RAIB has now made 11 recommendations in its report, nine of which are addressed to Network Rail, covering areas like improving its safe work planning processes and the monitoring and supervision of maintenance staff, and renewing the focus on developing the safety behaviours of all its front-line track maintenance staff, their supervisors and managers.
Bill Kelly, Network Rail’s route director for Wales, said: “Our thoughts remain with the family, friends and colleagues of Gareth and Spike and this tragic incident should never have happened on our railway.
“The safety of our colleagues and passengers remains our absolute priority and here in Wales we’re fundamentally changing the way we plan and deliver work: we’ve already halved the amount of work taking place while lines are open to traffic and are on course to dramatically reduce it further by 2022.
“A safety task force, comprising more than 100 people, has also been set up to further improve safety on the railway.
“We will continue to review and challenge not only our planning and process, but also our leadership and culture around safety.
“We owe it to Gareth and Spike to make sure we do everything possible to ensure this never happens again.”
Responding to the report, the chief inspector of railways, Ian Prosser, said: “Our thoughts continue to be with the families and friends of Gareth Delbridge and Michael Lewis, who were struck and killed by a train at Margam in July last year.
“Track worker safety is paramount and in the 18 months prior to the incident at Margam we undertook additional inspections following our growing concerns that Network Rail was not doing enough to control risks to track workers.
“These inspections had resulted in formal enforcement action being taken. Network Rail responded by forming a significant task force to bring about much-needed improvements.
“Our investigation into this tragic incident continues, however, the recommendations are welcomed.”