The Rail Accident Investigation Branch (RAIB) has published its report on the track maintenance trolley that ran away at around 3 am on September 11th last year. Writes Colin Wheeler
The incident happened at Haslemere but although the trolley ran downhill for 2.9 miles reaching a speed of about 10.5 miles per hour it remained within the overnight possession limits and no-one was injured.
It might easily have had consequences similar to the Tebay tragedy we all remember. Indeed the errant trolley ran through a site where another gang had been rail grinding. Fortunately a short section of level track and then a 1 in 93 rising gradient brought the trolley to a stand before it reached the next long section of downhill gradient.
Jammed brakes on a 1 in 80 gradient
The trolley was well laden with an estimated total laden weight of between 150 and 200 kg (below). The man in charge did not realise that they were on a falling gradient of 1 in 80. The brakes failed to operate automatically and the investigation identified failures in maintenance as a factor, stating that the “mechanism probably jammed with the brakes in the “off” position due to bent pushrods, the significance of which was not appreciated by either the maintainer or operator”.
Lack of safety culture at Havant
The most significant element of the report is the fact that no-one initially reported it! The RAIB report says “none of the staff involved reported the incident within Network Rail prior to receipt of the whistle-blower’s letter 10 days later”. The trolley remained in use.
The report says “staff went on using the trolley believing that it did not need to be examined or quarantined”. Predictably the report highlights “the training and competence of trolley operators as an issue”. But for me the most important factor which I am pleased to see in an RAIB report is identified as “the safety culture at Havant Depot”. I would add or lack thereof!!
Train struck a boulder
Headlines were made following the accident on June 28th when a diesel electric locomotive hauling 24 wagons from the North Blyth Alcan site to Fort William struck a boulder at Tulloch near Loch Treig and de-railed (pictured above). The locomotive came to rest part way down the slope and its first five wagons also de-railed all wheels.
The RAIB is investigating, but I would be interested to hear whether or not any local track staff had voiced concerns prior to the accident.
Two derailments in July
On 7th July this year another freight train derailed just north of Shrewsbury Station on facing points as it crossed from Down Main to Down Main Crewe. The train stayed upright but all wheels of the 16th coal carrying wagon came off. There were 19 wagons on the train and according to the initial report from RAIB “the left hand switch rail showed signs of wear”.
The investigation will focus on the condition of the track, including the points and the wagon. The RAIB are also busy investigating the derailment of a passenger train at Letterston Junction between Carbeston Road and Fishguard at 1845 hours on July 12th. The 2-car Class 150 DMU was travelling at 55mph when it ran into cattle on the line. Seven cows were killed or fatally injured but the 28 passengers and two-crew on the train were unhurt.
The suspicion is that the cows got onto the line at a footpath crossing half a mile away. I question whether local staff were aware of any defects in a cattle grid, if there was one?
Faulty neutral section splices
Network Rail’s Safety Central website features three ‘new to me’ Safety Bulletins. 261 refers to Seaward Line Testing Units for Direct Current (DC) lines which unbelievably some have been using without isolations being “proved” first. In another case the erroneous reading was due to the probe being used on a contaminated part of the conductor rail head.
262 describes the accident which befell two contractor’s men who were working on a 4-5 metre tall GRP scaffold when a cross member sheared. Both fell to the ground but are expected to make full recoveries. 263 reports on the discovery of a faulty batch of Arthur Flurry Neutral Section contact wire splices and the reasons for stocks being “quarantined until further notice.”
Track Safety Alliance Reports
I am pleased to see that addition of “Track Safety Alliance Reports” submitted by organisations working for Network Rail. The picture of the wrecked van following a road accident caused by its driver not taking enough rest before a night shift is a timely reminder to anyone tempted not to rest or to drive back after a long shift instead of lodging.
The identification of fraudulent CSCS cards is highlighted as are the dangers of using unmarked fuel containers and injuring finger ends when assisting with site unloading. The example quoted is of injured finger tips as a result of trapping them in the chute hinge of a ready mix concrete wagon whilst helping out with a concrete delivery.
Safety by Design
Last month’s article titled Safety by Design has resulted in correspondence. I have no argument with the principle. I recall inexperienced engineers with little or no site experience needed detailed supervision in the structural choices made at the initial concept design stage in particular.
When choices had been made, it was all too easy for detailing to be left to the young engineer who in many cases would need to modify details on site having been challenged by the Site Foreman; “How the *** do you think we’re going to build that??”
Safe to build and maintain choices need to be complementary to the structural and economic choices for designs. Safer to build designs make sense. But are our choices of design life and value engineering made with due regard to our railway inheritance of Victorian structures?
I was pleased to read in RailStaff last month’s report on “Carillion Lifeguards” and by what I have learnt since. I believe that improving the safety of rail workers is down to listening to those who do and supervise the physical work, be it manual or by machine.
Carillion’s campaign began on 23rd February this year following a forum attended by “operators and supervisors who shared their views on why more people didn’t complete “Don’t Walk By” forms (DWBs)”. Their opinions were heard. Subcontractors were rightly included in the launch event and most of their major subcontractors have launched the campaign to their people.
Operatives or workers
Project managers meet weekly, talk about DWBs and select a top 4. These are then included in that week’s task briefs and displayed in canteens. Each month a “Lifeguard Champion” is chosen from each site and is rewarded with a voucher and T-Shirt.
Their details are announced at the team brief so that they are recognised by everyone on that project. Their names, sites and specific safety concerns etc. are published every month in “Crew News”, a newsletter that is put on display in subcontractors’ offices.
Also each month a results sheet is published showing the chosen top 16 DWBs from all their sites so that everyone knows about issues raised elsewhere and can decide if they are applicable to their own site.
The one thing I don’t like is the use of the word “operatives” to describe those who do the work. We used to describe work gangs as “men”, nowadays we have many women workers on site so why not use the word “worker”?
The word “operative” sounds impersonal and reminds me of the bad old days of Railtrack when some of their people even referred to labour only subcontract workers as “the grunts”!
46% raised by workers in June
Carillion tell me that before they launched their campaign in January, 92% of DWB concerns were raised by “management”. This has dropped to just 4%, with 46% of the June DWBs being raised by operatives and the total number of DWBs each month has risen from around 20 to 100.
Categories used in the reports are “operatives, subcontractors, engineers, supervisors, managers, office and anonymous”. Mailboxes are provided and each listing also gives an 0800 number for those who prefer to ring in.
Subcontractor numbers still look a bit low in the couple of examples I’ve seen. In the May report although there were 17 anonymous, 14 operative, 9 supervisor, 5 engineer, and just 2 subcontractor reports there were also 51 from managers. So far as rail infrastructure is concerned I imagine CIRAS (Confidential Report and Analysis System) would be pleased to have such a level of reports.
Principles and Safety Culture
The principles are clearly right and it would be wrong of anyone to draw conclusions from a couple of months’ statistics. I welcome the initiative which is one of the very few I have heard of that attempts to get close and listen to the concerns of the site workers.
I am concerned that management and safety advisors may be tempted to take over the campaign. I would recommend the exclusion of most statements by and pictures of managers (or even worse, safety professionals). I recommend the regular repeating of last December’s Forum involving workers, subcontractors and supervisors giving them the risk-free opportunity to give their opinions and guidance on how this excellent initiative can be further improved.
I commend its principles to others who are serious in wanting to improve their safety performances, especially those who have already accepted that improving their safety culture is the way to go!
Finally spare a thought for the multi-sponsored rail professional who may work for a number of contractors and subcontractors. He or she is faced with a variety of safety systems like Carillion Lifeguards, all worthy but all different. Time to get the act together for safety’s sake?