Accidents caused by office planning and lack of good job specific briefings.

September 15th 2009

Support for COSS’s and site supervisors who want to plan their own work and visit sites before the jobs start!

A Welsh COSS with high blood pressure
Firstly my thanks to those who responded directly to last month’s article. I am always encouraged by the reasoned and enthusiastic feedback I get. This time I was first on the receiving end of an impassioned safety rant from a Welsh COSS (Controller of Site Safety) who I suspect periodically suffers from very high blood pressure!

He is not impressed by professionally produced COSS packs drafted by intelligent and competent people with little practical or local knowledge who spend all their time in comfortable offices. I know because he told me so!!

He advocates a return to mandated site visits by the COSS in daylight, carried out well before the work starts with the opportunity for the working method and safety protection methods being revised to improve safety. As he said the chances are that productivity as well as safety will be increased as a result. I agree!

A retired member of HMRI
Next a long retired area reader who worked first as a railway engineer and then as a member of Her Majesty’s Railway Inspectorate focussed on the role of the COSS having had his memory jogged by my reference to PICOW (Person In Charge Of Work), a term still used on Docklands Light Railway.
He reminded me that one of the reasons that Network Rail now uses the term COSS is to stress that the nominated person is to focus on safety rather than getting the work done. The original PICOW was understood to have the primary responsibility of getting the work done.

He went on to suggest that since we now accept that Site Wardens, (and where we still insist on using them Lookouts) have no other duties we should surely insist that a COSS has no other duties either. Their full attention needs to be on looking after the safety of the workers, especially in a moving group? I cannot fault his logic although there are cost implications.

Comprehensive, timely briefing information?
Next I came across the recently published report from our Rail Accident Investigation Branch (RAIB) on the accident which injured a track worker on a track renewal site a thousand metres north of Stevenage on December 7th last year. He moved into the path of the passing National Express 1540 Leeds to London train.

The Trac Rail Transposers (see picture) being used on the site are a useful piece of equipment. When used carefully they can improve productivity and reduce the chances of personal injury. Sadly few of those on the site were familiar with them according to the report.

The planning process did not fully identify the hazards of their use. The COSS’s record of arrangements and briefing forms and task briefing included no details. The COSS only received his Record of Arrangements, Briefing Form and Task Briefing sheet when he arrived on site. (The investigation confirmed that the planner had the relevant paperwork confirming his competence.)

Site lighting and a speed restriction
Due to their instability the site lighting columns were moved during an earlier shift, creating areas where the lights were obscured and some site staff were not equipped with helmet headlights either. Originally the lighting was to be between the two Up Lines but it was erected in the Up cess.

At the time of the accident work was being carried out between two road over-bridges (see diagram) over around 350 yards with both Up and Down Fast Lines under possession, but the Slow Lines were open to traffic.

Possession of the two Slow Lines had been used earlier between 0130 and 0530 hours to allow the machinery to be brought to the site of work. When these possessions were handed back, a 20 mph speed restriction was in place on the Up Slow for staff protection reasons.

The team were used to working together
The COSS and his team of five were used to working together. Their previous shift had ended at 0530 hours at Kentish Town on Friday 5th December. They arrived on the Stevenage site at around midday on Sunday 7th December.

The COSS regardless of the paper-work, realised that the distance between the Up Slow and Up Fast Line was insufficient for the use of a separated green zone (minimum width three metres without a Site Warden) so he briefed his team to make use of the ATWS (automatic track warning system) provided for those working with the transposers.

His instructions to his team were that when a warning sounded they should move to a place of safety using the four-foot of the Up Fast for this purpose. The ATWS was provided for the benefit of the Trac Rail Transposer operators who were instructed to lower their loads when it sounded a warning to make sure there was no possibility of anything swinging out into the path of a train.

Hit by the passing passenger train
By 1730 hours the work had progressed and five of the team were working adjacent to the relaying train whilst the COSS was standing close to a rail end held by a transposer. The two transposers were working together to move a section of rail adjacent to the Up Fast Line.

They carry a warning that track workers need to keep a minimum of five metres clear when they are working. As the train passed he was concerned that he was standing too close to the rail carrying transposer and hence moved away from it.

He was standing with his back to the passing train and was concerned by how close he must be to it so began to turn to look. By doing so he moved foul of the passing passenger train and was struck resulting in severe bruising and damage to his vertebrae.

Valueless paperwork?
Two specific statements in the RAIB report stand out; “the COSS Form contained no information specific to the worksite” and “the Task Briefing Sheet did not indicate the specific safe system of work to be used”.

I would argue that this effectively means that neither the COSS Form nor the Task Briefing Sheet had any value whatsoever to those doing the work. The Planner may have been passed as competent but had he experience of this type of work including the use of Trac Rail Transposers? If not should he have been asked to plan the work and draft the paperwork?

Transposers and ATWS
Coming back to the impassioned Welsh COSS who spoke to me. If the COSS’s and Engineering Supervisors had all visited the site in daylight and sat down and worked through the method of working, surely the job would have been better and more safely organised and everyone would have been aware of the hazards of working with transposers, the use of the ATWS, and the need for a planned safe method of working for the team whose leader so nearly lost his life?

I wonder whether the paperwork provided would even satisfy the specialist lawyers and safety professionals? We know it was inadequate for the work on December 7th! I do not believe that we need a further set of complex plant rules etc to cover transposers. A proper briefing to relevant track relayers on the use of transposer was all that was needed.

Less paper but more information and understanding
Network Rail are reorganising themselves with a move for many staff to Milton Keynes and streamlining of their organisation to meet the funding agreed with the Office of Rail Regulation.

Based on my experience from years ago, I recommend them to consider reducing office planning to the initial outline plans. Involve those who will be on site supervising and leading workgroups in the details. Initially it may look to be a costly alternative but both safety and productivity will improve as a result.

Rather than persisting with the again growing barrow loads of paper only the lawyers have a use for, we need minimal paperwork, which indicates only the specifics for each shift and job. The non-site specifics should have been trained and be so well understood that there is no reason to include them in briefings for each shift and job.

Five concrete planks fell onto the track
Sadly similar comments can be applied to the report following the investigation into the incident that occurred under bridge GE19 near Liverpool Street Station on May 28th last year.

There had been a lot of rain. The bridge deck had temporary supports at the eastern end. They failed at around 1917 hours resulting in five precast-concrete permanent formwork planks falling, with three landing on the track beneath.

Fortunately there wasn’t a train passing underneath at the time! Trains were stopped; passengers were evacuated with around 700 walking on to Bethnal Green whilst 350 walked back to Liverpool Street. The railway was closed for a total of 14 hours!

The causes included inadequate planning and lack of design of temporary works and unauthorised modifications to the temporary works. The report also highlights a “lack of sufficient method statement detail, the delegation of temporary works checking, lack of relevant experience of the site team and lack of ownership of the risks”.

If it went wrong it would be my fault
There are clearly parallels with the Stevenage near fatality, but the lack of ownership rings especially true to me. As a young and rather green bridge designer I remember well being sent out as an assistant resident engineer on to a rail overbridge site with a very experienced Clerk of Works. The Senior Resident Engineer had worked as a structural steelwork Site Agent and was a very competent engineer.
I relied on their detailed experience and apart from a bar chart, drawings and specifications we had very little paperwork. I was soon able to run my own sites, always based on the premise that if something went wrong it would be my fault and so I must always check that the contractor was working safely and “get the best possible job for the railway”. I wonder who had that responsibility for bridge GE19 on May 28th 08?

What caused the freight train derailment?
As I was completing this article news came in of the freight train derailment that occurred at midnight on 25/26th August at Wigan North Western Station. A Class 92 locomotive with 40 bogied container wagons, 8 fully loaded, three with a single container each derailed, beginning with the twelfth wagon, which was empty.

The train was travelling at around seven and a half miles per hour on the sharp curve going into platform one when it derailed. Another investigation for RAIB who have already ruled out signalling as a potential contributory factor.

I await with interest the results of their inquiry. Will it establish track or train maintenance or driving as primary or contributory causes? We will have to wait and see but I anticipate parallels with Stevenage and the Liverpool Street Bridge.

We have two options
We can pursue more and more systems with increasing numbers of dedicated safety personnel on site, and horror of horrors in offices. Alternatively we ensure that we have regular teams on site who know their jobs well and are empowered to organise their work themselves and carry it out safely knowing that they will be held responsible if things go wrong as a result.

There should also be rewards when they exceed expectations. If those doing the work are again permitted to take responsibility and become accountable everyone will gain.

 

Comments? Get in touch...

Email: colin at railstaff dot co dot uk

 

Colin will be speaking at the or come along to the IOSH Rail Industry conference 2009 on the 24th November.

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