The office of rail and road has successfully prosecuted its first case relating to poor management of worker fatigue. hopefully, it will also be the last.
As the details surrounding the death of two railway workers in a road traffic accident were explained in Nottingham Crown Court, it became clear that the driver was both overtired and underage to be driving the vehicle. Colin Wheeler considers the case and says that the industry must learn from this tragedy.
In my experience there are improvements in working safety and practices when a group works together regularly. If work is planned sufficiently early this is more easily achieved. This was evidently not the case when two welders were driving back from a second shift on 19 June 2013. Their vehicle “veered into a layby and hit a parked lorry”. The accident happened at Claypole near Newark and the van they were travelling in burnt quickly as it contained gas cylinders used for welding. The workers in the vehicle died in the accident.
On 20 March, in a prosecution by the Office of Rail and Road at Nottingham Crown Court, the company was found guilty of “failing to discharge its duty under sections 2 and 3 of the Health and Safety at Work Act 1974 and regulation 3 of the Management of Health and Safety at Work Regulations 1999”.
Just four and a half hours working time!
The driver aged 20 had driven from the Doncaster Depot leaving at 4:30am the previous day arriving at Alnmouth in Northumberland three hours later at 7:30am. The work did not take place so, at noon, some four and a half hours after arriving at Alnmouth, he drove back to the Doncaster Depot, arriving there three hours later at 3:00pm.
On arrival, he was asked by Renown to take on an additional welding team job at Stevenage. He agreed, this time taking a 47-year-old experienced welder with him, leaving the depot again at 7:18pm. They arrived on the Stevenage site about two and a half hours later at 9:47pm. They then carried out welding work between 11:15pm and 3:40am, after which they set off again, with the 20-year-old again driving. The accident happened at 5:30am, nearly two hours later at, Claypole near Newark.
Risk assessments and driving insurance
In Nottingham Crown Court, it was stated that the company’s fatigue management procedures were not followed and they failed to comply with the working time limits for safety critical work. These require a minimum rest period of 12 hours between booking off from a turn of duty and booking on for the next. The Court was also told that the company did not conduct “a sufficient and suitable risk assessment.”
In addition, the company’s insurance policy for the driving of company vehicles stipulated a minimum age for drivers of 25 years. Evidence heard on 20 March included staff advising that the age restriction for drivers was “routinely flouted”. A witness also told the Court that an initial decision that they had no one available for Stevenage was overruled by a more senior manager.
Four hours twenty-five minutes worked out of twenty-five hours!
It was a tragic and needless accident that should never have occurred. Further comment may be made once the sentence has been announced, but the sequence of events reflects badly on the industry. Between 4:30 am on the first day and the time of the road traffic accident on the second day at 5:30am (i.e. 25 hours later) the young man didn’t have 12-hour rest period. Ten hours and twenty minutes were spent driving, ten hours and sixteen minutes were spent waiting around and just four hours twenty-five minutes were spent working. It surely cannot have been planned that way?
Track safety training for train drivers
On 3 March, the Rail Accident Investigation Branch (RAIB) published its first ‘Urgent Safety Advice’ of 2020. It is titled “Passing between or close to the end of stationary rail vehicles in depots, yards or sidings”.
Organisations and individuals are urged to ensure that their staff are reminded of the risks of passing between or close to vehicles and that “suitable measures are in place to control the risks (such as training and local procedures)”. The Advice adds that using the Rule Book as the only basis for track safety training for train drivers and other operational staff is inappropriate.
Sadly, it makes no reference to the need for repeated reminders at safety briefings, meetings and personal discussions to ensure that the personal awareness of regularly encountered hazards remains high.
Driver suffered fatal injuries
The background to another ‘Urgent Safety Advice’ is the tragic accident that occurred around 8pm on 14 December last year at Tyseley Track Maintenance Depot in Birmingham. Having just alighted from the train he brought into the depot, a driver tried to pass between two stationary trains that were closely positioned on one of the sidings – RAIB’s reconstruction of the incident suggests that there was a gap of approximately 540mm between the gangway ends of the two trains.
As he was passing between the train ends, another driver in the cab of one of the trains next to the gap attempted to couple the two trains together, trapping the man walking between them. The reconstruction showed that the second driver would not have been able to see the pedestrian as he crossed the yard and entered the gap between the trains – he suffered fatal injuries.
COSS trapped at Manor Park
Network Rail’s Safety Central website is open to all and includes its “Safety Bulletins” which are, unsurprisingly, the most popular of the sections viewed. On 6 March, Network Rail issued a ‘Safety Alert’ following an incident at approximately 3:30pm on 22 February at Manor Park on the Anglia Route. Two RRVs (road-rail vehicles) were being used to work on the Overhead Line Equipment (OLE). Five hours into the shift, they were operating back-to-back with less than a metre between them.
Whilst linemen were working above them, track staff were transferring equipment between the two RRVs. One moved closer to the other “to assist in the equipment installation”. The machine operator sounded his machine horn confirming the movement to the Machine Controller. The machine movement trapped the Controller of Site Safety (COSS) between the rear bumpers of the machines.
Workers on the ground shouted, and the machine operator moved the RRV forward. The COSS walked out and went to the cess. The COSS fortunately suffered no broken bones or internal injuries but after a few hours was taken to hospital, possibly suffering from shock.
Runaway cement wagon
At 8:20am on 9 March, a loaded cement powder wagon ran away at Hanson’s Clitheroe Cement Works. It broke through the works gate and ran downhill towards Horrocksford Junction where the depot line connects into the Blackburn to Hellifield main line.
At an open level crossing it ran over a public road (two cars had to stop) and then an open crossing on a private road. Neither crossing had its manually activated warning equipment switched on before the wagon passed over. At Horrocksford Junction the wagon derailed at the end of the trap points run-out rails, so the trap points worked as intended.
RAIB’s investigation is underway and will include “the design and performance of the wagon braking system, how wagons within the works were controlled and any relevant underlying factors”.
Greenland Mill near miss
On 3 March, Network Rail issued a Safety Bulletin on its Safety Central website detailing a trackworker near miss at Greenland Mill on its Western Route. It describes a near miss that occurred on 26 February.
Members of the Westbury track team had planned to work under the protection of a shared line blockage of the Up Trowbridge line whilst they used hand tampers to lift and pack the track. However, they were involved in a near miss with a Colas light locomotive.
Very high-risk safety incidents
Network Rail’s own investigation is underway. In the Safety Bulletin discussion points readers are directed to consider how safety critical information is carried out when signing in to a line blockage with a Protection Controller and how everyone’s understanding is checked before authority is given for a line blockage to be shared.
The Bulletin also refers to Network Rail’s Handbook 8 section 4.1 where, under the heading “Protection at the Site of work”, readers are reminded that the instruction states that “you must place a red flag or red light on the approach to the worksite if the work will affect the safety of any approaching train or if a group is working”. The Safety Bulletin, understandably at this stage, makes no reference to the briefing given about the method of working before the team started work.
Network Rail’s Safety Bulletin NRB 20-03 describes an incident that took place at Adswood Junction. “Whilst an engineering train was being worked on, an RRV was propelled past on the adjacent track and could have injured an employee”. The Bulletin says: “There have been several very high-risk safety incidents in recent years.”
A tangled web of legally interpretable instructions and rules
The Bulletin adds that Handbook 12 – Duties of an Engineering Supervisor or Safe Work Leader – allows only an instruction from an ES (Engineering Supervisor) to be passed to the driver by a competent person, adding that this means only one holding ES competence. It adds that such instructions should be limited to identifying the train or on track equipment to which they apply, the movement location, route to be taken and maximum speed for the movement.
This interpretation/clarification (?) may support the relevant provision in the Rule Book but is it as practical, workable, simple and as safe as it should be? How will the recipients of this Bulletin issued to “line managers, safety professionals and registered contractors” understand and explain its contents?
Too many rules!
Years ago, I remember being disappointed after serving on a committee intent on simplifying and reducing the size of the Rule Book – it was a single volume but had grown too fat for the raincoat pocket. I did not have access to a safety professional or legal advice. We were all railway employees. Our objective was revising the rules and procedures to make them more easily understood and easier for the staff doing the work to understand.
Locally, we were using single sheets for each shift (printed one side only) with a diagram and explanation of what was to be done by whom along with the specified equipment, engineering trains and plant to be used. The details on those A4 sheets had been discussed with the relevant shift supervisors and agreed during a site visit in daylight. The objective was for each supervisor, technical staff member and trackman to understand and be committed to doing the work safely.
More rules result in less understanding!
We failed in our attempt to reduce and simplify the Rule Book. Sadly, the industry continued to increase the complexity and number of rules and regulations.
As our attempt at simplifying and reducing the thickness of the Rule Book got under way, it soon became clear that more rules had been added after almost every significant incident and accident. Indeed, our knowledgeable professional operator was able to give details of each accident that had added a further rule!
The result was a Rule Book that had more than doubled in size from the ones used in the 1950s. Surely, the greater the number of rules or equivalent, the lesser will be the understanding?
First fatigue management prosecution
The fatal road traffic accident that occurred back in June 2013 was tragic. Why, I wonder, has it taken so long to come to court? As the company is still working, changes must have been made to their working practices. What really went wrong?
To the best of my knowledge this was the first prosecution in England involving a failure to manage fatigue. My hope and prayers are for it being the last one too!