February 16th 2011The tamper operator who was struck by a 100mph passenger train and survived!
The RSSB Riddor review, and why 2011 must be the year when railway safety culture changes
Luckiest track worker alive!
As you read this David Higgins will be coming to grips with his new job as Chief Executive of Network Rail, and I feel sure that he will be putting safety very high on his agenda. If he and Chairman Rick Haythornthwaite needed a reminder of the importance of track worker safety they need only examine the incident that occurred just before midnight on Saturday January 8th near Tortworth Level Crossing in Nottinghamshire.
The injured tamper operator will be a strong contender for the 2011 title of luckiest track worker alive!
The Rail Accident Investigation Branch (RAIB) initial report says, "Just before midnight on Saturday 8th January a Tamping Machine Operator was struck by a passenger train while walking on the Down Main". The train was the 2200 hours from Kings Cross to Leeds and was travelling at around 100 mph at the time.
The Tamping Machine Operator was walking towards his machine, which was working under possession on the Up Main. At the time of the accident the Down Main was still open to traffic to allow the Leeds train (ID53) to pass, it being the last train of the night.
The RAIB says that "the Operator tried to move clear, but received a glancing blow to his left leg, his shoulder bag was pulled from his shoulder and carried away by the train. The tamper operator received severe bruising to the left leg and an injury to his shoulder. The train driver saw the tamper operator ahead and judged that he had moved clear. As a result the train did not stop but continued its journey".
We must wait for the RAIB report
One of the headlines to my article in January read, "In my book it can never be acceptable for those in offices to create confusion for those working on track". Although we will have to wait a while for the full RAIB report with recommendations, they have already said, "The investigation will include a review of the information provided to the Tamper Operator and the arrangements for staff to reach work trains located within engineering possessions".
It would be wrong to jump to any conclusions at this stage. But if no one ensured that the Operator knew that the Down Main was open to traffic until after the last train, and that he had been briefed on a safe method of getting to the machine, I would expect the investigation to ask why not!
"Deliberately not reporting lost time injuries"
The Rail Safety and Standards Board (RSSB) issued the final version of its RIDDOR Review on 25th January. For a while I have been stressing how important it is for us to improve the safety culture in our industry and remove the fears people have, which deter them from reporting accidents and incidents.
The RSSB review has been submitted to both Rick Haythornthwaite (Chairman Network Rail) and Lawrie Haynes who chairs the Company's Safety, Health and Environmental Committee. The report contains the following revelations: "the majority of the under reporting has resulted from deliberately not reporting lost time injuries".
The report states that over a five-year period RIDDOR accidents have been under reported by between 37% and 42%, equivalent to between 500 and 600 accidents. It also refers to an "indirect linkage to the assessment of the amount of bonus individuals across Network Rail are awarded", "changing relationships with contractors since 2005" and "fear felt by Network Rail staff and contractors if they report accidents and incidents".
Towards the end of the 100-page report it reasonably concludes that, "the review has identified underlying culture issues related to creating a more open and just culture that leads to effective industry learning and action." That I suggest neatly summarises the problem that the Chairman and Chief Executive now need to address.
The train struck a length of rail
That leads me on to wonder if a more open culture might have prevented the incident at Washwood Heath, near Birmingham on March 6th last year. A passenger train was struck by "A piece of rail being moved as part of maintenance work", according to the recently published RAIB report.
The 1919 hours departure from Birmingham New Street to Nottingham was a three car Turbostar Diesel Multiple Unit. It travelled on the Up Main until 1925 hours when, whilst travelling at around 80 mph it struck a length of rail being moved as part of a relaying job at Lawley Street on the through siding line at Washwood Heath.
At the time of the accident the Lawley Street through siding lines and Up Goods lines were under possession but the Down Goods and both Up and Down Main Lines were open to traffic.
Site staff did not co-operate fully with RAIB
There were two crew and 70 passengers on the train. The report says, "Site Staff did not report the accident although both the Machine Operator and Crane Controller were aware of it", but "the Driver stopped and reported the strike to the Network Rail Signaller".
The report also states bluntly "site staff did not co-operate fully with RAIB - withholding information about the accident from the RAIB Inspector who attended the site". The weekend of the accident was the second weekend of the relaying work and two further weekend possessions had been planned to complete the ballasting, tamping and de-stressing of the fourteen and a half lengths of relaying.
The possession booked for 1300 hours, had to be taken late at 1334 hours due to a late running freight train. One of the Road Rail Vehicles (RRVs) was late on site due to a defect on the machine. The RRVs were used to lift out the old track and that work was completed before darkness fell at 1751 hours.
An Unsafe System of Work
The report indicates that at the time the PICOP (Person in Charge of Possession) was acting in that role for the first time and was consequently being mentored. The Track Section Manager and his Assistant had 33 and 21-years of track experience respectively.
The Supervisor had changed the Safe System of Work to an unsafe system of work that according to the published report, "did not comply with the Rule Book or Network Rail's procedures"; "The Supervisor was not adequately managed and there was a lack of effective review of the Safe System of Work at planning and implementation".
The report adds, "The behaviour of the Assistant Track Section Manager discouraged challenge by his staff" and that "he had a drive to get the work done by 31st March".
Involvement in drafting the Safe System of Work
The RAIB examined the Safe System of Work (SSOW) form. It had handwritten additions on it and the wrong work item number. The report surmises that the Form was one from an earlier job that had been re-used. The original plan was for the RRVs to work from the Cess and Up Goods adjacent to the site access and away from the Lawley Street through siding (see plan Fig 2).
But the Supervisor (acting as a Crane Controller) instructed the machine operators to work on the Up Goods Line adjacent to the Up Main that was open to traffic at line speed. They were to stop work when warned of an approaching train by the lookouts despite the fact that darkness had fallen. This approach, whilst unsafe etc., removed the need for the rails to be double handled.
This could have been done safely and in accordance with the Rule Book etc. if trains on the open line had been restricted to 20 mph with warnings of their approach provided by the use of an automatic track warning system (ATWS), together with the appointment of a suitable person on site to be in charge of the method of working.
Not for the first time I am forced to comment that unless those doing the work are sufficiently committed to the SSOW (preferably by being involved in drafting it) they will always be tempted to try to do the work in a way they see as being easier.
Unexpected checks on working practices
For the future I hope we don't hear any more cries of "I will drive home my safety initiatives" or even worse "tell me where you found that happening and who was doing it and I'll see to it they never work again".
Listening management who respect track staff and work with them using their best ideas is the only safe way forward, and it will result in better productivity and lower costs.
We also need to re-educate those few Network Rail staff who still believe that "the rules are for contractors not us", and "I work for Network Rail so I can do this job my way". Equally wrong are the contracting teams who view Network Rail as "interfering amateurs and ogres dedicated to making our lives difficult who deserve to be hoodwinked whenever possible".
More regulations and rules are not the answer. We need far fewer, but an increased commitment to work safely at all times with managers acting as unofficial safety auditors, turning up when least expected to check for themselves on how the work is being done.
Apologies for confusion
In my January article I commented, "It can never be acceptable for those in offices to create confusion for those working on track". I welcome the words of Network Rail's letter of 4th February, "please accept our sincere apologies for the confusion caused. We have learnt from this issue of the Standard and will endeavour not to cause such confusion again".
The letter withdraws an earlier letter dated 17th November 2010 relating to the number of Work Experience Book (otherwise known as Log Book) entries needed for recertification of competencies. It also says that it now overrides what is stated in the Work Experience Books themselves! I realise it isn't easy, but the aim should surely be for consistent paperwork and that will be more easily achieved if there is far less of it!
My hopes now are for the emergence of an improving railway industry where long-term co-operative contracts exist and planners, designers, Network Rail staff, contractors and subcontractors all work closely together in teams to get the jobs done safely.
Passenger numbers are at their highest for decades and the future for our industry should be very bright and help the Nation out of recession. But it will only be able to do so if we all get our acts together, and 2011 is our best opportunity year yet!
We have it all to play for. With both Crossrail and High Speed 2 firmly fixed in our Government's sights, the future has never looked brighter for our industry. I also see McNulty as simply a challenge that needs to be met along the way!