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Accident reports and the way to a safer and more cost effective railway

August 4th 2009

An adder in the sun?
Last month brought two unusual safety bulletins, both dated July 17th. On 4th July two track workers were walking in the cess at Ramsden near Wickford when one of them was bitten by an adder. He was bitten on the ankle just above his boot but a quick trip to the local hospital was all that was needed. From my own observations I believe that our adder population has welcomed this wet but warmish summer so we all need to be careful!

Electrical energy released
On 16th July an accident occurred at a substation at Kenton Wembley. That was the subject of the second bulletin. It does not describe the accident in any detail but merely states that whilst a distribution team were setting up a safe system of work to test an 11kV feeder in a substation there was a “release of electrical energy”. The advice given for those accessing the back of the panel however includes “obtaining the correct key for the circuit breaker that has been isolated, and using the live line tool to prove the circuit is not energised.” The bulletin advises that further information will be issued following the initial inquiry. I commend those who issued the initial advice on the day following the accident.

Recent ORR reports
In my June and July articles I referred to the reference by the Office of Rail Regulation to the fact that last year we suffered the highest number of fatal accidents since 2005. I reiterated my view that we are too tied up with rules and procedures that few people fully understand and even fewer are interested in following. An examination of recently published Rail Accident Investigation Branch (RAIB) reports I suggest adds support to my opinions.

The team scattered
Just over a year ago there was what is described as a near miss at Acton West near London, when a passenger train ran into two rail mounted portable grinding machines and “the three members of the grinding team scattered as the train approached”. The 0015 hours Reading to Paddington train came through the crossovers from the Up Main onto the Up Relief. The picture of the crushed rail grinders underneath the train gives some indication of what might have happened if they hadn’t scattered. It was also fortunate and perhaps lucky that none of the twenty-five passengers suffered injury and the ruptured fuel tank was not set alight! (Each machine weighed around 117 kg).

The team had placed their grinding machines on the Up Relief line of the crossovers at Acton West and planned to push them towards Ealing Broadway. The COSS (Controller of Site Safety) did not know the area. The COSS pack he was provided with by someone who was also unfamiliar with the site, including the site safety arrangements and briefing form. According to the report these documents contained “closely packed script”, but in addition reference to a Five Mile Line Diagram was needed before they could be understood.

The Grinding Manager, according to the RAIB report had failed to reach the required standard in his Core Planner competency assessment. There is criticism of the fact that the Engineering Supervisor’s workload included one worksite, but within it there were no fewer than five areas of work within the possession. However, for me the most telling comment of all in the report is found in the “underlying causes” section. It states bluntly that, “the arrangements for preparing the COSS packs resulted in a lack of actual COSS involvement”. To my mind the paperwork can only ever be secondary to the knowledge and commitment of the man on site.

Near fatality to Patroller at Victoria
We have waited a very long time for the report into the near fatal accident at Grovenor Bridge London Victoria, which occurred on 13th November 2007! It is now available on the Rail Accident Investigation Branch website. The COSS, a Leading Trackman aged 47 years, had worked on the railway for sixteen years the last two of which were as a track patroller at Victoria. At Grovenor Bridge he walked behind the lookout, away from the line under inspection and towards the Up Chatham Fast line. He did not warn the lookout before he did so and failed to respond to the warning horn that was sounded. He was carrying a track spanner over his shoulder and was hit whilst in the six-foot between the Down and Up Chatham Fast lines by a train travelling at 27 mph (see diagram). The report also notes that the train driver “did not register the danger immediately nor sound further warning blasts or repeated urgent warning blasts on the horn”. His serious injuries included multiple fractures and brain damage. In addition to the COSS patroller and lookout on the day of the accident there was an additional team member. The report suggests that his presence may have, “changed the usual dynamics and reduced the ability of the COSS and lookout for working close to each other”.

The causes of the accident
The report lists the lack of a complete COSS briefing, the fact that the patroller was not wearing head protection and that the lookout did not challenge the COSS as he moved away from the line he was patrolling as, “contributory factors”. Even more telling are the listed “underlying causes”. These include “the close working relationship, culture and banter within the group”. In my experience this can be very positive in improving both the safety and efficiency of track working provided it is carefully managed by a prominent, frequently visiting and trusted supervisor. But another of the listed underlying causes is the “high level of administrative duties undertaken by the Track Section Manager which restricted his site checking of work”! (In my experience many of the best supervisors worked best when their paperwork was done by others- typically “light duty” people nearing retirement age.)

The lack of an ATWS
Deficiencies in the production and quality of the COSS pack are also criticised. This leads me to again question whether we should need them at all. If each and every COSS attended a possession meeting and made a site visit with the ES (Engineering Supervisor) before the weekend he or she could ensure they understood the safe system of work and how to apply it whilst seeing the site in daylight. All three track workers were Network Rail employees. I have criticised before the predominance of lookout protected red zone working by their maintenance organisation, which at best pays lip service to the RiMini planning process. I was consequently not surprised to read that the ORR has included the “lack of automatic track warning systems” as another of the underlying causes.

Green Zones-thinking strategically
The report highlights the fact that the Rule Book requires track staff to move to the designated place of safety, often the cess, when warned of an approaching train. It goes on to criticise the fact that at major junctions and in congested station areas there is no position of safety as such, but a local understanding that staff must move to another line as a train approaches them. The report includes the listing of the eight point RiMini hierarchy of protection with lookout protection as the last and least safe option. It refers back to a 2003 report by the Rail Safety and Standards Board, “Green Zones-thinking strategically”, which advocated an increase in automated inspections, a lower maintenance railway in busy stations and at bust junctions and timetables that include adequate engineering access. That report also called for improved possession planning, simpler rules and standards, better protection methods and better processes for the taking and giving up of possessions. That was six years ago!

A one way only sweep train
It would be wrong to restrict comments to Network Rail’s infrastructure alone and RAIB has recently published its report into a derailment at Deptford Bridge on the Docklands Light Railway (DLR). At 0522 on the morning of April 4th 2008 a Lewisham to Greenwich train hit a drilling rig that had been left on the track following engineering works. The train derailed on the 800 metres long viaduct, which is seven metres above ground level. The report highlights inconsistencies between DLR’s systems and those of its contractors but reserves its main criticisms for the omission of a sweep train. Sweep trains are usually run before passenger services resume. They run at a reduced speed with a passenger service agent sitting at the front of the train in the lead emergency driving position.

A common Rule Book for all?
Due to a misunderstanding between the passenger service agent and his Control Centre the sweep train operated between Poplar and Lewisham but the train ran in passenger mode on the return trip. The references in the report to the activities of the PICOW need to be read carefully by those who remember the same title being used for heavy railways. One of the report recommendations is for a common Rule Book for all who work on the DLR. Personally I should like to see a slim Rule Book, just the one, which includes short sections for DLR, London Underground, High Speed and Network Rail but is generally common to all three! After all there are track staff who work on two or more systems regularly.

What’s to be done?
Reviewing these accidents that happened a year and more ago leads me to the conclusion that to achieve the Office of Rail Regulation’s objectives for both safety and cost savings there is only one solution. We need track staff to own and be involved in the detailed planning of their work, and that means we need to stop festooning them with paper they don’t need. We need supervisors whose paper work is dramatically reduced so that they can fulfil their job titles and go back to supervising. We need planning of work, which is done by people with local knowledge and experience of doing the work themselves. We need to ban the last minute changes to weekend and indeed midweek work plans. We need to make sure that COSS’s as well as other staff involved directly in site safety management visit the site before each shift and become owners of the work system. Finally, and perhaps most important of all management needs to listen to the staff on the ground, hear their concerns and agree with them how the jobs can be done better. Cost savings and safety improvements will the inevitably follow. 

Full article with pictures Published in RailStaff July 09 edition.


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