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A near miss report and a track welder is killed

May 15th 2007

(and why paper is the biggest threat to track worker safety!)

I was pleased to see a copy of Network Rail’s Maintenance Safety Bulletin dated April 19th.

It reports a near miss with a welding team, which happened a month earlier on Saturday March 17th. I wish such incidents were more frequently reported and cannot but wonder whether a life might have been saved if it had been published earlier. Sadly we have lost the culture that encouraged, and indeed rewarded, the reporting of near misses.

Tragically this month and for the first time in a long while, I need to offer my condolences to the family and friends of the welder who was killed. He lost his life at Ruscombe Junction five miles west of Maidenhead on Sunday April 29th. For his family April 29th will be a date which is never forgotten. Tragically the fatal accident resembled the near miss in almost every detail.

The welder who lived

The near miss occurred at Tinsley Green Junction near Gatwick. A three-man team were carrying out weld repairs to the nose of 1732 points on the Down Slow line (see diagram). They were working red zone with the welder acting as COSS, an assistant welder and a lookout. When a train crossed through the site of work from the Up Fast to the Up Slow, both welder and lookout managed to scramble clear.

At the time the welder’s assistant was in the position of safety changing a grinding wheel. At this location the running lines are open for speeds up to 100 mph and the crossover for 60 mph.

The welder was sitting or squatting to carry out his work. The lookout was positioned immediately behind the welder giving horn warnings for trains approaching on the two slow lines and verbal advice when one approached on the Up Fast line. It is now understood that the safe system of work did not take account of movements between the fast and slow lines.

The welder who died

The welder was struck and killed by a train at Ruscombe Junction, five miles west of Maidenhead, on Sunday 29th April. He was also a member of a three-man team, this time made up of a COSS, the welder and a lookout. He was carrying out arc welding repairs to the nose of 850A points on the Up Main, protected by the COSS and a lookout who was giving a warning of approaching trains by touch. Lines speeds are up to 125 mph with 70 mph across the ladder.

An empty Great Western train, heading for Reading, approached on the Down Main and was signalled to cross to the Down Relief. This involved passing over 850A points where the welder was working in the four-foot. (See diagram) He was hit and fatally injured.

Both Network Rail and the RAIB have launched investigations into the accident. Meanwhile Network Rail has reminded COSS’s that red zone safe systems of work must take account of all train movements, which might pass through or close to their site.

Recognising that a train is changing routes

In recent years, a failure to recognise that an approaching train was changing routes has been a factor in several fatal accidents including those at Bradford Interchange (Oct. 2000), Waterloo (October 2001), Hitchin South Junction (December 2001) and Newbridge Junction (April 2005). It is all too easy, especially when working as a touch lookout with a welder, to get used to through trains and be caught out by the occasional one, which crosses over.

Weld repairs to switches and crossings are a useful and essential piece of work, which can prolong the life of S&C units. Is it now time we re-looked at how they are carried out? Maybe we simply need to raise safety awareness.

I still remember the first time I worked surveying under traffic in a station throat. An experienced local lookout relied on reading signals and indicators as well as watching for trains and kept me out of harm’s way. He was knowledgeable, reliable and well motivated. I never knew whether or not he could read or write.

I understand that at last Safety Net 30 will be with us “soon”. I hope the producers will include an item to focus on this special hazard.

“Meeting needs, meeting challenges”

I feel sure that both the family of the man who died and the welder who had the near miss will have been contacted by one of the fifteen Chaplains of the Railway Mission who are scattered throughout the country. Their presence and availability we so often forget until we feel we really need them.

Their motto “Meeting people, meeting needs” says it all. In their most recent newsletter, Sandy Kirkwood, who is Chaplain for the West Midlands and Chiltern Railways, suggests they might rename their motto as “Meeting People - Meeting Needs - Meeting Challenges”. He comments that as a Chaplain he cannot produce miracles but can offer assurance and support with confidentiality. (If you want to learn more, why not visit their web site www.railwaymission.org).

“Flawed records of who was responsible”

The various inquiries are underway and will inevitably reveal additional factors - they always do. Meanwhile in their 27th April edition the Guardian newspaper expressed their frustration with the long wait for the reports into Grayrigg, Cumbria. They referred to investigations by Network Rail, the Rail Accident Investigation Branch and British Transport Police.

Their reporter wrote of “flawed records on maintenance checks” and “incomplete paperwork-including instructions and record keeping”. His true aim became obvious when he suggested there were “flawed records of who was responsible”.

The fatality at Ruscombe didn’t make the newspaper headlines but the “great British Press” is impatient for a story, which blames an individual for Grayrigg, allows them to assuage the thirst generated by our blame culture and throws work to the lawyers.

The patrolman had learnt his trade

I have a better idea, which might just improve things for everyone. I remember giving evidence in Crown Court following a passenger train derailment, which occurred at high speed. The local patroller had been recruited and trained by the same supervisor who he worked for at the time of the accident. Neither was exceptionally good with pen or pencil.

Back in those days the Rules were read out loud again and again when the weather was bad. Those events were recorded. He had learnt his trade, for that is what it is, from more experienced staff who kept periodic checks on his patrolling records and helped him in his early days. He was committed.

Waiting to be called to give evidence he was understandably nervous. But he said to me “I am sure there was nothing wrong with the track”. In the end my evidence on track quality ensured that he was never called. As the engineer I knew him and his supervisors and how good they were at their jobs. I had walked that section myself not so very long before the accident.

The records we had were a small patrolman’s notebook, supervisor’s patrol books, cab riding records, action slips etc and in a big ledger, details of all inspections. Above all, I had a conscientious team focussed on doing the job. We neither needed nor used lots of paper or computer records.

Two finger typing

Many years later I was asked to investigate contract patrolling and track maintenance following a passenger derailment somewhere else. Local patrollers were as committed and capable as I hoped they would be. But in place of their notebooks they had to record faults by computer code to suit the software system. Some faults did not fit the codes. They also said that it was OK when light duty supervisors did the inputs. They could tell them about specific problems.

However in the interests of efficiency and to reduce costs, trained typists who were so much faster than the two finger typing light duty men, now did the inputting! To ensure they had all the required paper records, sheets with tick boxes had been provided - with the ticks already inserted, they merely had to be signed!

Knowledge, expertise and judgement

Have we gone too far? Computer records are excellent tools. The essential work be it S&C weld repairs, track inspections or renewals is only as safe as those doing the job make it. If you are told that filling in the forms and recording the data is equally as important, you will be more likely to do something else wrong. If you feel that your knowledge and expertise is valued and your judgement respected you will try to live up to it.

I have met too many who say that achieving this month’s target or indicator number is the primary objective. That should never be the case. Pride in doing the job right because it’s for the railway, never taking chances ...these were the principles of days gone by, when with inferior systems and far less paperwork, we still managed to work safely.

The Modular Rule Book

The modular Rule Book has never been a great success. Originally those who worked on it were told that individuals would only need one or two modules. We were also told that there would never be those silly stick on amendments, which many failed to use, merely a re-issue of the complete module.

Last Christmas we got another set of stick ons!! Now Graeme Bickerdike, after boasting of being a young man, suggests that our Plain English Rule Book may lose its Crystal Mark. I will not be surprised. The operating and Rule Book gurus insisted on keeping specialist words and phrases despite the Plain English Society’s protests. As Graeme says it is about to get worse still.

Who uses it? Who really understands it? I suggest the answer is operating and Rule Book gurus together with a few specialist fee hungry lawyers. Let’s scrap it and put something simple and very concise in its place. With modern technology and higher levels of literacy we only need a Rule Book half the size of the one we had 50 years ago!

Reduce the recording and paperwork

We took a long time to admit that the Method Statement paper chase had got way out of hand. Now is surely the time to focus on reducing computer records and paperwork so we all focus on the job to be done?

Network Rail’s SAF 7 initiative is about safety culture and motivation. Before the investigation work is done we need to agree that less paper, much less paper and more open, trusting, non-confrontational working together needs to result, for safety’s sake.

The same is true of computer records. We can make good use of measured data in engineering decision making but keeping records to make lawyers lives easier is not only wrong, but can make us less safe.


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