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Personal responsibility and accountability supported by many more unexpected site visits by chief executives

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Sadly I must begin by reporting a fatal accident that occurred on May 1st on the new Borders Railway Project. Writes Colin Wheeler

A 54 year old Bam Nuttall employee was driving a tractor and trailer south on the A7 just north of Galashiels when a lorry ran into the back of his trailer; “the tractor driver was injured and was subsequently reported deceased at the scene”. My thoughts and prayers are for his family and friends.

An HOBC near miss

On Wednesday 23rd April this year there was a near miss at Tollerton on the East Coast mainline on a High Output Ballast Cleaner (HOBC3) worksite whilst the team were being protected using LOWS (Look Out Warning System) equipment. Investigations are ongoing.

With the letting of new track renewals contracts for both plain line and switch and crossing renewals, it was also announced that when the existing high output renewal contracts run out (March 2015) Network Rail will take direct control of their national high output track renewals. Their objective is the simplification of their organisation. Around 1,200 people work on these contracts at present.

The injured car driver reported his accident

At 0310 in the early morning of Friday May 31st this year a car driver was forced to swerve into metal fencing to avoid colliding with an engineers’ train equipped for weed spraying as it passed over Balnamore Level Crossing (between Coleraine and Ballymena).

The crossing is equipped with automatic half barriers that are normally operated by approaching trains, but with a possession of the line having been taken the crossing should have been under “manual local control”. When the engineers’ train passed over the crossing the half barriers had not been lowered and the road traffic signals were not operating.

After the accident the crew of the engineering train spoke with the car driver (who like his passenger had suffered minor injuries) before continuing with their work. They did not report the accident but the car driver did by contacting Northern Ireland Railways later that same day.

No checks on weedkilling

Northern Ireland Railways require “safety checks to be performed on a periodic and random basis to include visits to sites of work”. Their safety professionals and heads of department are to undertake these checks but the latter often delegate this work.

The investigators found no evidence of any safety checks on weed-killing during 2013. The RAIB report found that the weed-killing team were “routinely not complying with the rules relating to the operation of half barrier level crossings

within possessions”. It goes on to say that they found a “low perception of risks” a “desire to complete the weed killing work more quickly” and that “non-compliance was not detected or corrected by safety checks”. Whilst not within RAIB’s remit one wonders about the management responsibility for the work.

Did the Conductor forget?

A year ago there was a near miss at Llandovery Level Crossing between Shrewsbury and Swansea. At 0556 in the morning of Thursday June 6th a van drove over the open crossing immediately in front of a passenger train.

A witness working in a garage adjacent to the crossing saw it happen and reported the incident to the police. The train conductor is supposed to operate the crossing using the control panel provided on the platform at Llandovery Station. This had not been done.

The RAIB report comments that the “opportunity to integrate the operation of Llandovery Level Crossing into the signalling arrangements was missed when signalling works were planned and commissioned between 2007 and 2010.” I assume the Office of Rail Regulation (ORR) approved those plans.

Heavy concrete trough units

Following its concerns during the Bristol/Swindon area re-signalling works last year the ORR has issued a Prohibition Notice in respect of the manual lifting and carrying of the big C143 concrete troughing units. This process began following an ORR site inspection of those works.

On May 19th this year Mace who are working on the Birmingham Gateway Project issued their own Safety Alert after three separate incidents when ducting had slipped from the forks of either fork lift trucks or Genie Lifts.

In two of the incidents (none of which fortunately resulted in any injuries) the safe working loads of the machines had not been exceeded and the cause was the size of the ducts. In the third incident the safe working load was exceeded. The bulletin admits that there were “issues with the lifting plans and those operating the equipment outside its capacity”.

Who is responsible for visually checking for potential landslips each year?

The RAIB has recently issued a report on landslips on Network Rail’s infrastructure. This is in reaction to the six landslips which occurred between June 2012 and February 2013. The investigation focussed on land adjacent to the railway, adverse weather and on risk management.

The findings and five recommendations highlighted the fact that expert examinations may be carried out at frequencies of ten years and concluded that meanwhile there was a “lack of clarity about who should carry out visual checks” between examinations.

Why had no-one discovered the problems with radio messaging and TPWS?

On March 20th this year a freight train passed Greenford Junction in the south east. The following passenger train then passed two signals at danger. It passed the first red signal at 20 mph and then went through the second one that was only 142 yards further on. It then proceeded over the junction onto a single track section as it headed towards South Ruislip and the freight train.

Eventually the driver responded to an emergency phone message and stopped his train 1.75 miles past Greenford Junction. The investigation is proceeding but has already established that the Train Protection Warning System (TPWS) had self-isolated, and the Greenford Signaller was unable to send a radio message to the driver, so the Greenford Signaller had to call on a Marylebone Signaller to do so.

Tight curve and no check rail but other factors too

An RAIB report was recently released about the derailment at Ordsall Lane Junction in northwest England of a Class 47 locomotive that subsequently caught fire. The locomotive derailed on a small radius curve whilst being hauled at the end of an empty train of five coaches.

The hauling locomotive was also a Class 47. It ran on derailed for 70 metres before coming to a halt when a fire broke out on the locomotive. The leading right hand wheel had climbed the unchecked outside rail whilst travelling at just 14 mph.

Although the arrangements for rail lubricating had just been modified the outer rail face was dry and clean and the locomotive had just left Ardwick Depot following wheel re-profiling after it had been found to have wheel flats. There was also some gauge widening on the curve.

It was concluded that the fire was caused by a fractured fuel pipe near to a severed electric cable. At 178 metres the curve was below the minimum radius of 200 metres which is the standard below which check rails should be provided, but it was 192 metres at the point of derailment in the transition curve.

Many rules, standards and instructions – but personal accountability?

The majority of this month’s selection of safety related events reflect errors of judgement by individuals or are examples of motivated people taking short cuts to get jobs done as they see it more easily.

More worryingly I suggest are the findings or probabilities that incidents really occurred because no one individual was fully and personally responsible for the safety of the infrastructure or the equipment that was in use. This responsibility ultimately goes to the top.

The importance of unannounced site visits by the boss 

At the recent annual Rail Safety Summit a number of speakers rightly emphasised the importance of unannounced site visits by senior managers and chief executives. One specifically commented that he knows when he has left too long a time between his site visits by the ease or otherwise with which his employees speak up when he meets with them.

The recently published Rail Accident Investigation Branch (RAIB) report into a level crossing incident in Northern Ireland illustrates an extreme case of the results of too few site visits and management being unaware of what was going on. But surely patrollers have commented about potential landslips, mess room talk has identified difficulties with bulky concrete troughing; and had none of Greenford’s Signallers discovered the problem with using driver radio communication?

Maybe you know the answers to these questions? If so I will be pleased to hear from you.


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