Absence of lookouts contribute

A LACK of lookouts was partially responsible for the deaths of two track workers at Margam East Junction in south Wales on

July 3, according to an interim report published by the Rail Accident Investigation Branch on December 5.

The two men were working on points P9577B when they were struck by a Swansea-London Paddington train, operated by Great Western Railway, at around 0952 ( RAIL 883).

The report says that three workers at the site (one of them survived) were almost certainly wearing ear defenders because a loud power tool was being used, and that none was aware a train was approaching until it was too late to move to a position of safety.

“The absence of a lookout with no involvement in the work activity removed a vital safety barrier,” says the report.

Paperwork issued to the team was also scrutinised. RAIB found that one safe work pack (SWP) identified two safe systems of work. The first was that work on the Up Main line at Margam

East Junction was to take place between 1230 and 1530 and that a line blockage had been arranged. The second system (designated ‘parallel’) indicated that work could take place on both Main lines with warning provided by lookouts between 1230 and 1530.

However, another SWP was created on June 27 for work on

July 3, relating to another worksite near crossover 9550 - 1.6 miles from Margam East Junction in the direction of Cardiff. One of the two safe systems of work stated that work on the Down Main line would take place between 0830 and 0930 protected by blockages between 0830 and 0930. The other (also designated ‘parallel’) indicated that work could take place on both main lines with warning provided by lookout at those times.

RAIB says the presence of two separate SWPs, one for work near crossover 9550 and the other for work at Margam East Junction in the afternoon, “appears to suggest an intention that work at the two locations be carried out sequentially”.

However, it adds that witness evidence suggests some of those involved did not interpret the paperwork in that way.

“There appears to have been a widespread belief that the times shown on the SWPs related only to the availability of line blockages, rather than determining when the work at each location could take place. RAIB observes that 12 workers would have been far more resource than was needed to carry out each of the work activities that had been identified at each site,” the report says.

It adds that the two systems of work recorded in the SWP for Margam East Junction were interpreted to mean that work could be carried out on either the Up or Down Main line with only unassisted lookout warning, with the option of taking line blockages from 1230 if needed.

In its report, RAIB says: “The RAIB observes that the plan for the work at Margam East Junction provided no clarity on the safe system of work that should be adopted for each element of work. It provided two parallel safe systems of work

- a line blockage on the Up Main line with a parallel safe system of work, based on unassisted lookout warning, on the Down Main line.

“However, the document could also be reasonably interpreted as also allowing work on the Up Main line using unassisted lookout warning. This lack of clarity and understanding may have allowed the planner, supervisors and workers to believe that they had freedom to choose the system of work the group should adopt, rather than working to the plan and the times of the planned blockages.”

The report identifies that there was insufficient visibility of approaching trains in the area for a single site lookout to provide adequate warning time for the work at points 9577B, but that the system of work in the SWP did not specify the need for a distant lookout.

RAIB also concludes that the system of work the Controller of Site Safety proposed to implement before the work began was not adopted, and that alternative arrangements “became progressively less safe as the work proceeded that morning”.

Further investigation will review the group of track workers’ dynamics, an assessment of working practices at Port Talbot depot at the time of the accident (with a particular focus on the way maintenance teams were managed and supervised), and an examination of the arrangements in place to monitor compliance with track safety rules.

It will also review the selection, training and assessment of the track workers, particularly those with responsibility for leading groups, and examine the organisational culture and its impact on safety behaviours.

RAIB will continue to examine the suitability of the planned system of work, and review NR policies relating to: enabling sufficient track access for maintenance activities; the extent of management knowledge of the informal and non-compliant systems of work that appear to have become established; and how widespread these were at Port Talbot and elsewhere.

The actions of the industry to reduce the occurrence of accidents and near misses involving track workers in the years leading up to the accident will be examined.

And the effectiveness of the warnings provided by the train’s warning horn in all of its possible settings will be evaluated.