The RAIB’S annual reports look back at accident investigations over the last twelve months and makes some recommendations for the future.
Safety expert Colin Wheeler reviews the report and picks up on one suggestion, that the UK adopt the concept of White Zone Working. He says: “It is time for us to end the dangerous practice of work and inspections of track being done whilst trains are running. Flags, whistles, horns and detonators or their electrical equivalents are not good enough!”
On 21 May, the Rail Accident Investigation Branch (RAIB) published its annual report covering activities between 1 January and 31 December last year.
The report includes a series of summary documents highlighting safety learning from six categories of railway accident that, taken together, are the cause of 40 per cent of RAIB’s investigations.
During the year, RAIB received 391 notifications, leading to 51 preliminary ‘examinations of evidence’. These led to 23 full investigations that will be or have been published as reports or safety digests.
In 2019, RAIB published 17 reports and 10 Safety Digests, plus one interim report and an Urgent Safety Advice. Together, these generated 57 recommendations.
Altogether, since RAIB became operational in 2005, it has published 447 investigation reports.
In writing the report, RAIB’s chief inspector, Simon French, comments: “2019 saw a significant number of investigations involving one or more fatalities.” He adds that four reports were published relating to fatal accidents – three to members of the public and one to a member of staff. Additionally, at the time when the report was published, four further staff fatalities were under investigation.
I congratulate Simon French and the RAIB on this year’s report. There are still lots of statistics, graphically presented, but this year the focus is on just six types of railway accident, featuring them as “key learning documents”. This is an improvement. For me, it evokes memories of the format under which I worked when we received annual reports from Her Majesty’s Railway Inspectorate, signed off by its Chief Inspector, who was usually a retired senior army officer!
The six listed accident types are all supported by numbered appendices entitled “Summaries of Learning”. Those featured are:
- Design and operation of user-worked level crossings and, in particular, how to manage the interface between road vehicle users and the railway. There are 5,800 level crossings in the UK – 1,500 are across public roads. Between 2005 and 2019, RAIB investigated 47 collisions and eight near misses. 34 of these incidents occurred at user-worked crossings.
- The protection of trackworkers from moving trains. Since 2005, there have been 45 incidents involving track workers – eight resulted in fatalities and 12 in injuries. 22 such incidents have occurred in the last five years.
- The management of risk at the platform/train or tram interface, in particular, incidents in which people are trapped in train or tram doors and dragged along the platform. Research indicates that 58 per cent of passengers wrongly believe that doors will always reopen if obstructed.
- The safety management of abnormal train operating events that put passengers and crew at risk, such as trains becoming stranded between stations. Drivers, signallers and operations controllers “may have little experience of stranding incidents,” the report states, adding: “There is a need for improved planning and enhanced training.”
- Freight train derailments: “These create the potential for collision with passenger trains and can cause massive damage to infrastructure. Areas for safety learning include vehicle design, condition, uneven loading and track condition.”
- The safe design, operation and maintenance of on-track plant and trolleys. Summaries of Learning lists vehicle braking, operator competence, vehicle conversion and trolley/trailer braking systems. The listed incidents between 2009 and last year include seven runaways and two collisions, all resulting in RAIB published reports.
Margam and Tyseley
In his comments, the chief inspector remembers the shock we all experienced when two track workers were killed by a train at Margam, Port Talbot, in July last year and the death of the train driver caught between two trains as he walked between them at Tyseley Depot, Birmingham, on 14 December.
Adding a personal note, with which we can all empathise, he recalls attending the site of a fatal accident involving a track worker and the profound effect it had on him. He commented: “The railway is like a family, with a distinct culture all its own, and we all feel deeply the loss of our colleagues. It’s especially traumatic for those who witness such accidents, including work mates and train drivers.”
The Margam detailed investigation is still progressing but, on 5 December, RAIB published an interim report.
Safer on LU and DLR
Forty-four track worker investigations were carried out between 2005 and last year – Simon French stresses the need for planning that is smart and accurate.
He added that railways such as London Underground and Docklands Light Railway already impose strict separation between people and trains. Consequently, neither has ever featured in an RAIB investigation in which track workers were at risk from moving trains.
He also added that some European railways, including France, timetable ‘White Periods’ in the daytime off-peak hours, during which no trains are scheduled to run, enabling safe access for inspection and maintenance. He acknowledges that parts of our mainline network are heavily trafficked during the daytime, but suggests that, where safe night-time access is easier, cyclic maintenance tasks should be undertaken.
Reduced reliance on lookouts
The report states that, in Scotland and on the LNE Route of Network Rail, there is a shift away from reliance on lookouts, which is well overdue in my opinion! Simon French acknowledges the importance of observing the track under load and responding to faults. But he lists: “fundamental requirements that have been highlighted time and again by RAIB’s investigations.”
These include leadership on site, identification of site hazards, provision of concise accurate and relevant information, improving the clarity of voice communication and reducing reliance on the vigilance of individual workers to warn of approaching trains.
He also advocates a greater use of technology to control access to the railway infrastructure, provide warnings of approaching trains and in protecting possession limits.
The report tactfully describes the introduction of Network Rail’s “Planning and Delivery of Safe Work” with “specially selected safe-work leaders” as having yet to be achieved. It adds that, in the latest edition of Network Rail’s 019 standard, the creation of the Person-in-Charge role is not adequately addressed.
The report reminds us of the track worker who died after being hit by a train at Stoats Nest, some eight months before the Margam fatalities. Simon French says that the track worker was working on a zero-hours contract and highlights the pressure on individuals trying to “juggle multiple jobs to make ends meet”. He suggests that the effects of patterns of employment on fatigue and fitness to work are significant.
Fine for fatigue fatalities
Following prosecution by the Office of Rail and Road and conviction in Nottingham Crown Court under the Health and Safety at Work Act for “failing to ensure that two of its workers were sufficiently rested to work and travel safely”, fines were imposed on their employer.
Two track staff died in a road accident on their way home from overnight work, as described in my April article in Railstaff. In a virtual court hearing on 13 May, their employer, was fined £450,000 plus £300,000 costs.
No more lamps and detonators!
I was delighted to read that the RAIB has queried the “continuing requirement for people to go on track to place and remove red lamps and explosive detonators”.
I recall, from my track working life, experiencing atrocious conditions one winter when a lone trackworker was struggling to put such “protection” in place in freezing temperatures with limited visibility due to falling sleet not very far from Shap summit!
The report lists near-misses and fatalities resulting from the need to place and remove “protection” at Reading in 2007, North London in 2017 and Peterborough more recently.
Simon French’s conclusion is that “there needs to be a culture which absolutely rejects risk taking as a means of getting the job done”.
Stranded between stations
Under the section headed “Management of stranded trains and passenger self-detrainment” the report highlights the importance of “decisive action in the early stages of an incident” and the need for an “overarching control and command strategy”.
It states that several recent investigations have focussed on the circumstances that led to passengers getting out and walking along the tracks whilst the adjacent conductor rail was still live!
Trapped in locked doors
Since 2005, RAIB has investigated sixteen events when objects, including bags, a pushchair, dog leads, hands and arms, have become trapped in closed and locked train or tram doors. A recurrent theme is the mistaken assumption that door control systems will always detect the presence of something trapped. They don’t!
I recall writing about a number of these and have seen passengers stretching out hands and arms in attempts to get closing doors to re-open.
This part of the report states simply that there have been too many incidents of machines running away downhill. Investigation of an incident at Bradford found fault with the machine operator’s actions, and badly maintained brakes failed to hold the machine on a 1 in 46 gradient.
At Cholmondeston, in Cheshire, a road-rail vehicle (RRV) ran into a stationary personnel carrier, resulting in a staff member suffering a life-changing injury. The report is critical of the conversion of what they describe as a road lorry, which had to travel long distances in reverse with unaltered driving controls, leaving the driver to turn around to try and see where he was going over the top of the ballast being carried.
The report says this was a case of “inadequate consideration of the practical aspects of using such a machine on the railway”.
Under this heading RAIB’s report describes the potentially dangerous disappearance of temporary speed restriction details from storage in the signalling system software of the Cambrian lines.
It also refers to the disruption on 9 August last year, when problems on the National Grid led to a dropping of the frequency of the Overhead Line supply to below 49 Hz for just 16 seconds. As a consequence, 57 Class 700 trains operating north of London locked out their traction power systems and became stranded with reduced lighting and no air conditioning.
Although 27 were recovered by using a simple reset process, the other 30 (that had been updated using a software patch) had to await manual restoration by a technician using a laptop to connect into the train network and restore their power systems.
This reaction to the reduced supply was as designed but had not been specified by the client.
Croydon Tram tragedy
The report acknowledges the progress made in implementing its recommendations following the Sandilands Junction tragedy on Croydon Trams. However, Simon French points out that research has not yet identified a practicable way of improving the containment of passengers by the windows on the existing tram fleet. RAIB has agreed with the Office of Rail and Road that more needs to be done for future tram builds.
In the report’s concluding remarks, Simon French praises the dedication and professionalism of his team of inspectors and those who support them, and acknowledges the support provided by both the British Transport Police and the Office of Rail and Road.
What now needs to be done – White Zone Working
Now is a moment of opportunity, due to the reduced number of services running, to make a start.
The use of previously installed and remotely activated track circuit operating devices as replacement for flags/limit boards and detonators for all possession working needs to becomes standard practice as soon as possible.
Re-signalling and remodelling schemes should only be accepted by the Office of Rail and Road if they provide signalling controlled “white zone” access for planned and unplanned inspection and work on track. Arrangements should also be adopted for routine maintenance work and inspections only being carried out during the “white zone”, when trains are not running. Future timetables need to include “white zone” provision.
Prioritisation of this conversion should be based on risk and, consequently, should begin with main routes in and around our major cities and on main lines. Those who argue that to do so would add unacceptable costs to railway operations should be reminded of the cost and anguish that results from each and every fatality!
Simon French says in the annual report that “the railway is like a family with a distinct culture all its own”. This needs to be reflected, by the introduction of legislation if necessary, in the employment conditions of all those who work to inspect, maintain, operate, renew railway infrastructure and service and repair trains.