Formal Inquiries

Clay Cross report and recommendations

Railway Safety has issued its formal inquiry report into a train striking and injuring a signalling and telecommunications technician at Clay Cross on 5 June 2002.

The formal inquiry was convened under independent chairmanship and included representatives on the panel from the involved parties. As with all such inquiries the panel's task was to establish the immediate and underlying causes of the accident and make recommendations to prevent or reduce the risk of recurrence.

Sequence of events

At approximately 1036hrs on 5 June 2002, a Balfour Beatty Rail Projects Ltd Signalling and Telecommunications (S&T) Technician was struck and seriously injured by 1F10, Midland Mainline's 0825hrs service from St Pancras to Sheffield, at Clay Cross.

Two S&T technicians had been designated to isolate point condition monitoring (PCM) equipment in trackside cabinets at Clay Cross. They worked independently of each other, the injured technician taking responsibility for two cabinets located at Clay Cross North Junction (CCNJ).

The driver of 1F10 approached the junction at approximately 80mph (128km/h), observed the technician on or adjacent to the Down Main sleeper ends and sounded a warning horn. The technician acknowledged the warning yet failed to move to a position of safety. The driver then sounded the horn a second time. The technician recognized the approaching train and at the last moment attempted to jump clear of the impact, however was stuck by the leading power car.

Conclusions

The formal inquiry panel concluded that the immediate cause of the derailment was that despite having heard and acknowledged the warning horns the technician failed to look for the approaching train and therefore seek a position of safety. He did not realise the danger he was in until it was too late.

In this instance the Panel was unable to conclude with any certainty what all of the underlying causes may have been. Some of the following causes (**) therefore have a speculative element about them. Unfortunately, the injured party was unable to recall any detail that might have clarified these matters. The underlying causes of the accident are summarised as follows:

• A failure to define and/or use an available access route to the cabinets that would have avoided the need to cross any running lines.
• The preparedness to cross lines where there was insufficient sighting distance that would have allowed him to reach a position of safety at least 10 seconds before a train arrived.
• ** The Technician may have been confused, thinking that he was next to a slower line (88km/h) rather than the faster Down Main (128km/h), coupled with some ambiguity or disregard for the Rule Book as to what constitutes a position of safety.
• **The technician may have suffered a lapse of concentration leading to an auto-response to the warning horn.
• **The possibility that the Technician, knowing that his colleague was also working in the vicinity, assumed that the horn was intended for his colleague rather than himself.

Recommendations

The report makes recommendations for improvements in a number of key areas and these are summarised as follows.

• Staff should be instructed to gain access to equipment or buildings via access points and routes which do not require the crossing of running lines.
• Access points and routes to equipment etc, which avoid the need to cross running lines, should be drawn up and included in method statements and safety briefings.
• Where sighting times would not allow them to reach a position of safety at least ten seconds before a train arrives, staff should contact signalers to verify that it is safe to cross.
• Staff requiring to go on or about the track, whether walking or working, should notify the local signal box of their presence on arrival, and again on departure.
• Actions should be taken to ensure that all staff receive safety briefings.
• Method statements must include local details to ensure that they are relevant for the task and the location.
• Individuals Working Alone should be required to complete risk assessment identifying and controlling all hazards in preparation for their work.

Railway Safety has issued a full copy of the report to each member of the Railway Group and the other organisations involved in the accident. All recipients of the report need to review the findings and recommendations and take actions where appropriate to address identified deficiencies within their own systems. Railway Safety will track the industry's response to this report.