Track deaths: no lookouts for unnecessary work
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
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.”