A report by Colin Wheeler.
An incident at Rochford, Essex, showed that, far from there being a safe system of work, it wasn’t safe and there was no system.
The Rail Accident Investigation Board (RAIB) report into an incident at Rochford in Essex on 25 January 2020 describes a dreadful site situation followed by an equally inadequate response from on call staff.
RAIB chief inspector Simon French has drawn attention to this report and the potential for fatalities, adding “the investigation found a catalogue of errors and omissions, duplicated lines of control, and a lack of clarity about who was in charge”.
He highlights the current need for Network Rail to find a more effective way of managing the movements of multiple vehicles within a work site.
Operator needed help!
Work on the electrified overhead line, during a scheduled possession beginning at 02:15, involved using a wiring train and seven MEWPs (Mobile Elevated Work Platforms) to remove wiring on the Up line.
The possession was delayed by the wiring train and not taken until 03:28. Six of the MEWPs were on-tracked and travelled to various work sites. MEWP 10 was not on-tracked until 09:30. Its operator was working his first shift after several months and needed the assistance of a supervisor to on-track the machine and carry out the necessary brake test. Individual machine supervisors were provided for each MEWP, together with a POS (Plant Operations Scheme representative).
Between January and June 2014, 134 accidents and incidents involving on-track plant were reported. Subsequently, Network Rail introduced its on-track plant operations scheme, for which companies are required to provide representatives on site.
A fault developed on MEWP 2, needing a fitter who was taken to the machine from the access point by MEWP 10 (see diagram).
Whilst MEWP 10 travelled at 7mph (walking pace is stipulated) to MEWP 2, its supervisor stayed at its site of work. It was intended that the MEWPs would work in pairs back-to-back, with each machine supervised by a machine controller and each pair of machines managed by a site supervisor.
Supervisor shouting and running after the machine!
At 10:50, the operator of MEWP 10 discovered that the required slings were not in the machine basket, so the operator and linesman began to search and asked the staff of MEWPs 2 and 3 if they had spare ones. Without involving the machine supervisor, MEWP 10 then set off towards MEWPs 2 and 3, leaving the supervisor shouting and running after it – he was unable to keep up as it reached 10 mph.
A fitter working on a platform sensor fault on MEWP 2 saw MEWP 10 approaching and shouted a warning to colleagues on and around MEWP 3. MEWP 3’s machine supervisor realised that a collision was inevitable when MEWP 10 was just 15-20 metres away.
MEWP 3’s headphone-wearing operator and linesman did not hear the warning and the impact threw them against the basket framework. Both were wearing safety harnesses and only sustained minor injuries, for which they received hospital treatment.
ES was in a Supermarket!
The PIC (Person in Charge) was contacted at 11:10 but was managing two other MEWPs near Southend station, so the site supervisor was asked to manage the situation – the POS representative was not involved. The site supervisor for MEWPs 2 and 3 contacted the ES (Engineering Supervisor), who was in the local supermarket but “did not know what he needed to do and had no training in managing the situation or competence in accident investigation”.
Both the PICOP (Person in Charge of Possession) and Romford operations centre were contacted, and the Anglia Route Operations On-Call manager was asked to attend site and collect evidence. The On-Call Anglia Route Maintenance manager was asked to attend in support.
Half an hour passed with no response from either of them, so Route Control contacted the MOM (Mobile Operations Manager), advising that drugs and alcohol testing had been arranged. The On-Call Maintenance Manager arrived on site at 2:16 pm but waited for the On-Call Operations Manager.
Neither On-Call manager arrived with PPE and one advised that they had been attending a social event.
RAIB contacted the Operations Manager confirming the types of evidence to gather, but this was not done.
The comprehensive RAIB report lists the causes:
The MEWP operator drove at more than walking pace (actually reaching 10mph) and lost awareness when driving towards a stationary MEWP;
The Machine Controller was unable to effectively supervise MEWP 10;
Site organisation was not conducive to safe management of supervisory roles on site, there was a lack of clarity about roles and responsibilities leading to confusion among staff about who was in charge of the safe movement of on-track plant;
Network Rail’s Overhead Condition Renewals Organisation (OCR) valued “getting the job done over rule-compliance and safety”;
A culture of disrespect existed towards contractors undertaking the role of machine controller within OCR worksites;
Network Rail had been unaware of the poor working relationships and culture and the extent of non-compliance on OCR sites, and its management assurance process had not identified these issues;
Network Rail’s incident management and on-site investigation were inadequate and resulted in a lack of co-ordination and loss of evidence.
Personal accountability and responsibility
During my time working from British Rail’s divisional offices, I recall being On-Call for almost 20 years. Bleepers were replaced by huge brick mobile telephones and we all carried details of procedures and contacts specifying actions and contacts if accidents and incidents occurred. I kept a separate folder for dealing with injury accidents and fatalities. Failure to attend and take action when called out was unthinkable.
The RAIB report identifies a lack of team spirit, excessive supervisory roles that were neither understood nor, apparently, of use, cultural site conflicts and on-call individuals who were neither mentally or physically equipped to respond when called out to an accident.
This report describes such a dreadful state of affairs that I sought the opinion of the Office of Rail and Road (ORR). I spoke with Anna O’Connor, principal inspector of railways and also ORR’s head of projects for its Network Rail division. We agreed that the report was far reaching and that its recommendations were to be welcomed. Also, that the duplication of supervisor roles looked to be the result of successive additions and updating by safety professionals.
Overall, we both agreed that the circumstances that resulted in the accident were simply awful!
Anna confirmed that there was a lack of team spirit at Rochford and probably other overhead condition renewals (OCR) sites, exacerbated by the hazardous excess of supervisory roles. She also agreed that the failure of the on-call management team was unacceptable in timescale and in dealing with the accident.
I commented that, when I undertook call-out duties as a railway civil engineer, I was judged by my speed of response and the actions I took on arriving on site. When on-call, attendance at any social event was necessarily off the agenda.
When I asked about the reported “cultural conflicts”, she confirmed that this was the case and that a degree of racism was also evident and systemic. The mixture of staff on site, from a range of different employers did nothing to foster a spirit of trust and cooperation.
Having discussed the poor safety culture that exists within current OCR organisations and the importance of suitable on-call staff, Anna expressed her support for the RAIB’s recommendations, particularly the first two listed in the report.
The first directs Network Rail to “reduce the confusion among staff responsible for operating and controlling the movement of on track plant, leading to the adoption of unofficial systems of work”. Simplifying plant movement rules and reducing supervision, as well as harmonising or changing the circumstances that are in the way of committed team working, including using a number of different organisations, needs to be addressed.
I advocate forming teams that stay together over long periods of working. This will, if well managed, be safer and more productive.
The second recommendation identifies the need to improve the management of the Sentinel system, including the way in which trainers assess English language skills, which we agreed are especially important for those undertaking safety-critical work.
Anna O’Connor commented that she has personal experience of inadequate training in Personal Track Safety from biannual renewal course attendances. I recommended the introduction of “mystery shoppers” to assess training organisations. Having undertaken the role occasionally years ago, I recall it as being easy to perform and effective. Unannounced audits randomly selected would be effective and provide measurable information on the effectiveness of the training.
I would like to thank Anna O’Connor and ORR for discussing the findings of this report so frankly. Now we all have to make sure they are adopted as soon as possible.