Rail (UK)

Track deaths: no look­outs for un­nec­es­sary work

- An­drew Ro­den Con­tribut­ing Writer rail@bauer­me­dia.co.uk Swansea · London · Paddington · Great Western Railway · Network Rail Route 18 · Rail Safety and Standards Board · Department for Transport · United Kingdom Department for Transport · Rail Accident Investigation Branch

THERE were no look­outs to warn track work­ers who were in­volved in a fa­tal ac­ci­dent in South Wales of ap­proach­ing trains - and the work they were doing was un­nec­es­sary.

On July 3 2019, two track work­ers were hit and killed by the 0929 Swansea-Lon­don Padding­ton, op­er­ated by Great Western Rail­way, at Margam East Junc­tion. A third came very close to be­ing struck ( RAIL 883).

The Rail Ac­ci­dent In­ves­ti­ga­tion Branch re­port into the in­ci­dent found that the three work­ers were car­ry­ing out a main­te­nance task on a set of points, but be­cause they were al­most cer­tainly us­ing ear de­fend­ers and one of them a noisy power tool, they had be­come fo­cused on their task and were un­aware of the ap­proach­ing train.

The in­ves­ti­ga­tion, which fol­lows in­terim find­ings in De­cem­ber

2019 ( RAIL 894), con­cluded 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 pro­gressed, cre­at­ing con­di­tions that made an ac­ci­dent more likely.

The work­ers in­volved in the ac­ci­dent were loos­en­ing, lu­bri­cat­ing and retight­en­ing a threaded fas­tener on a slide base­plate/dis­tance block assem­bly of points 9577B while both lines con­nected by the crossover were open to traf­fic.

In­ves­ti­ga­tions found that Net­work Rail’s Work In­struc­tion NR/L3/TRK/4004 states that fas­ten­ings should be fully tight­ened on assem­bly to the re­quired torque.

This means that the bolts and nuts of switch slide base­plates and dis­tance block fas­ten­ings are con­sid­ered to be as­sem­bled for life at the fac­tory and should not need to be dis­man­tled while the switches are in ser­vice.

There are no NR track en­gi­neer­ing stan­dards, work in­struc­tions or other guid­ance notes which re­quire this work to take place as a sched­uled main­te­nance ac­tiv­ity.

RAIB’s re­port notes: “Net­work Rail’s pro­fes­sional head of track was un­able to think of any rea­son why this should be car­ried out as a sched­uled task, and other en­gi­neers whom RAIB has con­sulted agree.”

Un­der­ly­ing fac­tors were iden­ti­fied as the in­ves­ti­ga­tion con­sid­ered why NR had not cre­ated the con­di­tions needed to achieve a sig­nif­i­cant and sus­tained im­prove­ment in track worker safety.

The first was that NR 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.”

The sec­ond was that NR had fo­cused on tech­no­log­i­cal so­lu­tions and new plan­ning pro­cesses, but not ad­e­quately taken into ac­count the va­ri­ety of hu­man and or­gan­i­sa­tional fac­tors that can af­fect work­ing prac­tices on site.

The third was that NR’s safety man­age­ment as­sur­ance sys­tem was in­ef­fec­tive in iden­ti­fy­ing the full ex­tent of pro­ce­dural non­com­pli­ance and un­safe work­ing prac­tices, and did not trig­ger the man­age­ment ac­tions needed to

iden­tify them.

Eleven rec­om­men­da­tions were made, with nine ad­dressed to NR. They cov­ered its safe work plan­ning pro­cesses and the mon­i­tor­ing and su­per­vi­sion of main­te­nance staff (three rec­om­men­da­tions); re­new­ing the fo­cus on de­vel­op­ing the safety be­hav­iours of all its front­line staff, their su­per­vi­sors and man­agers; and es­tab­lish­ing an in­de­pen­dent ex­pert group to pro­vide con­ti­nu­ity of vi­sion, guid­ance and chal­lenge to its ini­tia­tives to im­prove track worker safety.

Other rec­om­men­da­tions cov­ered im­prov­ing the safety re­port­ing cul­ture and im­prov­ing the as­sur­ance pro­cesses, the qual­ity of in­for­ma­tion avail­able to se­nior man­age­ment, and the pro­cesses for as­sess­ing the im­pact of changes to work­ing prac­tices of front­line staff (three rec­om­men­da­tions).

An­other rec­om­men­da­tion is ad­dressed to the Rail De­liv­ery Group, in con­sul­ta­tion with NR and RSSB, which rec­om­mends re­search into en­abling train horns to au­to­mat­i­cally sound when a driver makes an emer­gency brake ap­pli­ca­tion.

A fi­nal rec­om­men­da­tion is made to NR, in con­sul­ta­tion with the Depart­ment for Trans­port, rel­e­vant trans­port au­thor­i­ties, the Of­fice of Rail and Road and other stake­hold­ers, to in­ves­ti­gate ways to op­ti­mise the bal­ance be­tween the need to op­er­ate train ser­vices and en­abling safe track ac­cess for rou­tine main­te­nance.

RAIB Chief In­spec­tor of Rail Ac­ci­dents Si­mon French said: “This ac­ci­dent has re­in­forced the need to find bet­ter ways to en­able the safe main­te­nance of the rail­way in­fra­struc­ture.

“The ar­eas that need to be ad­dressed to im­prove the safety of track work­ers have been re­peat­edly high­lighted by 44 in­ves­ti­ga­tions car­ried out by RAIB over the last 14 years.

“The most ob­vi­ous need is for smart and ac­cu­rate plan­ning to re­duce the fre­quency with which trains and work­ers come into close prox­im­ity, while also meet­ing the need for ac­cess to as­sets on an in­creas­ingly busy rail­way sys­tem.

“I be­lieve it is es­sen­tial that Net­work Rail ad­dresses the fun­da­men­tal re­quire­ments that have been high­lighted by RAIB’s in­ves­ti­ga­tions over the years.

“These in­clude: de­vel­op­ing leadership skills and in­volve­ment of the site team in the plan­ning process, in­clud­ing the iden­ti­fi­ca­tion of site haz­ards and the lo­cal man­age­ment of risk; bet­ter man­age­ment of peo­ple who work on the track, in­clud­ing su­per­vi­sion and as­sur­ance, that will make sure cor­rect work­ing prac­tices are in use, and to iden­tify ar­eas for im­prove­ment; and greater use of tech­nol­ogy to con­trol ac­cess to the in­fra­struc­ture, to pro­vide warn­ings of ap­proach­ing trains or to pro­tect pos­ses­sion lim­its.”

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