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Safety awareness & culture need to improve

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Colin Wheeler

I was pleased to see the recent updating of Network Rail’s Safety Bulletins on their Safety Central website which is accessible to all. Network Rail says they are “regularly sent out to staff”. Hopefully, all relevant employers of staff working on Network Rail’s railways use them to brief their people.

It is more important than ever that supervisors and managers reinforce safety culture via face-to-face discussions with their staff. Personal commitment is needed. I recall from years ago the efforts made by Trades Union Safety Representatives, whose dedication and commitment contributed hugely to the safety culture in the railway industry.

A near miss and contractor fall

On 5 April, a report was issued describing how a contractor was seriously injured on 11 March. The individual was working on wooden infill in Clapham Depot carriage wash area adjacent to the parapet when the wooden infill collapsed, resulting in a fall of 20 feet onto another section of railway below.

The incorrect installation of Emergency Speed Restriction (ESR) equipment “on multiple sites” was reported on the Safety Central website relating what are described as “several instances” during 2023. On April 30, a near miss with a trackworker was reported on a limited clearance underbridge at Chiltern Green Luton.

Recent RAIB report

On 27 March, the Rail Accident Investigation Branch (RAIB) issued report 02/2024 about the derailment of a tram at Bulwell, Nottingham on 12 June last year. It was at 17:05 when a southbound tram, travelling at 25mph “approached a set of facing points in an unsafe condition”. At the north end of Bulwell tram stop it travelled over points but the tram’s first and second set of bogies “were routed in different directions.”

The tram derailed and struck an overhead line pole supporting the overhead wire. As a result, a pane of glass was dislodged and struck a passenger causing a minor injury. The tram driver was also injured. The spring-loaded points were in an unsafe condition having not reset after the passing of two north bound trams. A visual indicator located alongside the points was “not observed by the tram’s driver”.

The driver believed they would be informed if there were any issues with a set of points but this had not occurred. The report speculates that “the driver had probably been conditioned to there being no issues at this location and was probably distracted.” Report 02/2024 makes three recommendations, all to Nottingham Trams Ltd. It is to “review control room policy and procedures to ensure that clear and practical guidance is available to manage the response to engineering faults.”

Secondly, RAIB highlights the need to “improve risk assessments in the light of this accident”. The third recommendation concerns the “consideration of human factors when assessing the effects of a prosed engineering change”. Having read the report carefully I hope their drivers regularly attend safety meetings, recommend improvements, and are able to raise concerns.

Near miss with track worker

This incident occurred on 14 March this year at 14:14 hours on the Up Fast line close to the junction with the West Coast Mainline. It involved a train travelling at 110mph. The track worker involved believed the Up Fast was blocked, but the line blockage agreed with the signaller applied to the Down Fast not the other road. Following a preliminary examination, RAIB has decided to publish a Safety Digest!

Derailment at Grange over Sands

On 22 March around 06:05, a passenger train travelling between Preston and Barrow in Furness derailed after crossing over a length of track that was unsupported and gave way as the train passed over. It was travelling at 56mph and the first three of the six coaches derailed. The train struck a wall at the top of the embankment but remained upright, coming to rest about 30 metres beyond the cavity.

Four passengers and four staff were on the train but none of them were injured. However, there was “significant damage to both the train and railway infrastructure”. RAIB is seeking to “identify the sequence of events and will consider the condition of the railway and drainage, the planning and management of maintenance, management of local flood risks, and any underlying factors”. I expect to read a full investigation report in due course.

Near miss at Fishguard

On 10 April, RAIB released its Safety Digest on this near miss that involved a trackworker who was acting as both Person in Charge (PIC) and Controller of Site Safety (COSS). The incident took place on 4 January at around 09:46 and involved a train travelling at 53mph some three and a half miles south of Fishguard.

The workers were a small team of agency workers whose job was to clear vegetation for a principal contractor. The planned work was to be done using a “separated system of work” with staff remaining at least two metres away from the nearest open line. As the train approached, its driver saw the PIC on the track! The train’s horn was sounded and the emergency train brake was applied. The PIC moved off the open track two seconds before the train passed.

The train driver reported the near miss to Clarbeston Road signal box and then continued the train’s journey. RAIB’s Safety Digest states that the PIC had strayed outside of the safe area that had been published in the planned safe system of work. The site is on a bi-directional single track between Clarbeston Road Junction and Fishguard Harbour Station. It is on a sharp curve “with vegetation further restricting the view for train drivers”.

Image from forward-facing CCTV taken from a different train, showing the access point in the foreground and the bridge in the background. Credit: RAIB

The access point permits eastern access from a roadside gate next to a bridge carrying the railway over a road. From the gate a grass path rises parallel to the track with railway on either side. At the top the path turns towards the track and then leads into the cess.

Preparation of the Safe Work Pack (SWP) was done by the principal contractor and was received by the PIC three days before the site work began. It covered a section of track including the sites planned for the day. Planned access details for that morning were listed, as was the egress point at the other end of the work around four miles away. The SWP also blandly advised that “various authorised access points within the mileage could also be used for access”. There were no specific SWP’s for each site nor any individual consideration of risks. The hazard directory did not include any details of limited clearance at the bridge.

The plan required the PIC to “establish a separated system of work to protect the team from moving trains”. Site Wardens must have no other duties, and no one should enter any closer than two metres from an open line. A site warden may not be needed, provided a three-metre separation can be achieved. Two operatives met the PIC around 09:00, were briefed at the access point, and signed the briefing form. One of them also signed to confirm undertaking the duties of a Site Warden!

They walked up the path to the first strip of vegetation to be cleared. Work began between the path and railway boundary. The PIC then asked the other operative to use the cess to locate the next area to be cleared, but was unaware that the next strip was the other side of the bridge beyond the limited clearance area. The operative moved out of sight of the PIC who stayed on the access path.

On hearing an approaching train, the second operative and PIC moved towards the track to “get a better view of the first operative’s location”. They both stumbled and ended up on the track. Closed-circuit forward-facing pictures from the train cab showed the train’s speed to be 53mph. Following the near miss, the trackworkers left the site almost immediately without either completing the work or reporting the incident. The SWP did not include any details of limited clearance at the bridge and the PIC had not visited the site before the work took place, and consequently was unaware of the limited clearance before going on site.

Ponton Yard access point from a train travelling south on the up fast line.

Train collides with RRAP equipment

This accident occurred on 19 December 2023 at 06:03. A passenger train was damaged when it ran into parts of road/rail access point (RRAP) left on the track at Ponton Yard near Highdyke on the East Coast Main Line. RAIB’s Safety Digest 02/2024 was issued on 17 April. Road/Rail on-tracking had been attempted the previous night following which the RRAP was “unintentionally left on the track”.

Planned inspection and maintenance was one of the activities south of Grantham. The portable RRAP had two metal ramps to be placed outside the running rails and two locally modified lightweight, high density foam ramps to be placed between the running rails. These were made from a commercially available kit, but the modification had not been approved by Network Rail nationally.

Uncontrolled self-evacuation

RAIB’s Report 03/2024 titled “Uncontrolled evacuation of a partially platformed train at Clapham Common London Underground Station” was updated on 8 May. The incident took place as long ago as 5 May 2023 at around 17:43. An underground train departing from the station was halted by a passenger using the emergency alarm after smoke and a smell of burning entered the train. It came to a stand with two cars inside the tunnel and four adjacent to the platform. Around 100 of the 500 passenger self-evacuated using the interconnecting doors between the cars and the train windows.

Some train windows were broken by passengers both from inside the train and from on the platform. After a delay of four and a half minutes, station staff began opening train doors. A few passengers reported minor injuries. Clapham Common Station has a narrow island platform which the report says increased the risk of passengers falling onto the track and potentially being exposed to the conductor rail or trains approaching on the adjacent southbound line.

Passengers beginning to evacuate from the train via the broken window.

The report refers to the increasing alarm of passengers when the trains doors remained closed and the delay which took place before information and action became apparent from London Underground staff.

Train driver in near miss

On New Years Day at 09:30, a freight train carrying dangerous goods activated a hot axle box detector (HABD) at Netherfield Junction, east of Nottingham Station. Signalling brought the freight train to a stand. While its driver was examining the train on the Up line, a passenger train was allowed to leave Nottingham Station on the Down line. Its driver saw that the driver of the freight train was on the track and in the passenger train’s path.

The passenger train’s driver braked and used the train horn to give a warning. The freight train driver reacted and moved clear. After bringing the train to a stand the passenger train driver reported the incident to the signaller.

A new era?

My optimistic, but I hope realistic, post-election aspirations are for a reorganised and well-motivated railway, free of industrial action that, operates safely. Currently, there are simply too many accidents and incidents. I worked in the industry for 17 years while fulfilling an on-call commitment. I have too many bad memories. On today’s railways there is still plenty more that should be done.

Image credit: RAIB