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Formal Inquiries

Cranberry report and recommendations

Railway Safety has issued its formal inquiry report into the accident at Cranberry on the West Coast Main Line that occurred on 13 February 2002 and resulted in a track worker suffering major injuries to both legs.

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 reccurrence.

Sequence of events

A nine-man team comprising a Controller of Site Safety (COSS), two welders and six agency workers were to rectify a defect just north of Cranberry. The task was to remove and replace a short length of damaged rail. It was not possible to establish a safe system for this work without having a 20 mph speed restriction on the adjacent Fast line.

A Temporary Speed Restriction (TSR) application had not been submitted so it was decided to impose an Emergency Speed Restriction (ESR) on the Down Fast before the commencement of work. This involved installing a portable Automatic Warning System (AWS) magnet in the 'Four Foot'.

The COSS and four of the agency workers set up the ESR warnings whilst the rest of the team went on to the worksite. It was decided to install the magnets between trains. Removal of ballast in preparation was carried out under lookout protection but when this was done an agency worker was left alone to fit the magnet. Whilst he was attempting to clamp the magnet to the base of the rails he heard an approaching train and although he attempted to dive out of the way he was struck by the locomotive and suffered severe injuries to both his legs.

Conclusions

The inquiry concluded that the accident happened because a safe system of work had not been established for the installation of the portable AWS magnet. Underlying this immediate cause was a complex string of underlying causes stretching from initial failures at the pre-planning stage through to failures to comply with track safety rules on the night. These are summarised as follows:

  • Failure to comply with the Rule Book requirements for working on the track during the hours of darkness and an assumption that lookout protection would provide a safe method of working.
  • Communication failure between COSS and the workers that resulted in one worker being left alone, in darkness to work on a line open to traffic.
  • Failure to apply for a TSR during the pre-planning stage.
  • Failure to recognise the need for T(ii) protection to enable the setting up of an ESR and perception at ground level that a T(ii) would be difficult to obtain at short notice.
  • Failure to prepare a method statement for the work.
  • Lack of an effective manpower allocation system leading to an inexperienced team arriving on site.
  • Lack of supervisory checks on night work activities over a period of six months.
  • Absence of formal track skills training for the agency workers.
  • Inadequate pre-work briefing of the workers.
  • Lack of a system for ensuring that the agency workers have the opportunity to discuss safety issues and raise any concerns about site safety.

Recommendations

The report makes recommendations for improvements in a number of key areas.

  • Establishing a system for checking worker experience, competence and hours worked etc to enable the COSS and other supervisors to check that the planned manpower is available.
  • Establishing training for track workers so that they are able to carry out their work with knowledge of the hazards and the established safety arrangements.
  • Establishing compulsory regular safety meetings for all agency workers.
  • A review of the COSS competence assessment process to ensure consistency throughout the industry and independence of the employer.
  • The contractor to establish a system for monitoring long term vacancies in supervisory and management positions and make arrangements to ensure that the safety related duties of the posts are undertaken.
  • Signal boxes to have voice recording equipment.
  • Emergency planning to ensure that all signal boxes have information on access points to the railway which can be passed to the emergency services.
  • Railtrack to complete its review of protection arrangements and introduce a system which would enable a safe system of work to be implemented quickly between COSS and signaller.

Remedial actions

In addition to recommendations the panel also set out a number of remedial actions to comply with existing requirements. These include:

  • The contractor to remind its workers that TSRs and ESRs are only to be set up in accordance with the Rule Book.
  • The contractor to remind all COSSs to conduct pre-work briefings in a suitable environment and confirm understanding of work and safety arrangements.
  • The contractor to produce method statements for all routine track activities and apply the requirements during planning and implementation of the work.
  • The contractor to review its work planning process to ensure that all equipment and resources necessary to carry out the work in accordance with the method statement are available to the COSS.
  • The contractor to brief its supervisors on the Railtrack Company Standard RT/LS/S/019 'Protection of People Working On or Near the Line'.
  • The contractor to remind its supervisors and COSSs not to use ESRs when undertaking non-essential work.
  • The agency to remind its supervisors and managers to report to Railtrack any instances where workers are denied future employment after they have refused to work because of inadequate safety arrangements.
  • Railtrack to issue a publication setting out the objectives and procedures for the legitimate use of the right of workers to refuse to work when they consider the safety arrangements to be inadequate. This topic should also be addressed by Railtrack, its contractors and sub-contractors in their next planned safety meetings with workers.

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.