Formal Inquiries

Cheddington report and recommendations

Rail Safety and Standards Board has issued its formal inquiry report into a track worker fatality at Cheddington on 20 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 around 2200hrs on Thursday 20 June, a group of Balfour Beatty Rail Projects Ltd (BBRPL) track staff, employed by Watford Bletchley Alliance (WBA) project, arrived by van at a location know as Site A, north of Cheddington Station and South of Ledburn Junction and unloaded tools an equipment in the area being used for a permanent-way preparatory works. The gang was to undertake work in a green zone beyond the cess adjacent to the Up slow line. The look out began to conduct other members of the gang to the work site (at around overhead line gantry 37m o6) across the Fast lines (which were under possession arrangements and then across the Slow lines which were open to traffic at line speed.

AT 2212hrs the lookout had conducted three members of the gang to a place of safety clear of the Up Slow line, adjacent to the intended site work, and was about to conduct a fourth, when Silver link train 2B86 (Birmingham New St-Euston EMU)travelling at line speed on the low line, struck and fatally injured him.

2B86 came to a stand on the approach to Cheddington Station at 2213hrs and the driver advised the signaller in Watford PSB the he thought he had struck something near Ledburn Junction. At around 2220hrs, Bletchley PSB received a call from a Balfour Beatty employee advising that a man had been hit by a train and required an ambulance.

Conclusions

The formal inquiry panel concluded that the immediate cause of this accident was the lookout not being in a position of safety for the passage of 2B86. The panel concludes this may have been due to one or more of the following reasons:

• Misjudgement of his own position in relation to the Up Slow line
• Misjudgement of the speed of the approaching train
• Temporary confusion over which line the train was approaching on
• Distraction caused by watching other gang members about to cross and the 1G44 on the Down Slow line
• A lack of awareness of the approach of 2B86 behind him, whilst he was acknowledging 1G44 on the Down Slow line.

The panel also believes than an underlying cause of the accident was the failure of the site supervisor and the COSS to establish a safe system of work, including site access. Whilst a method statement was available for the original erection of the scaffold, and this identified the appropriate access at the Skanska site, it was not clear to the panel that this method statement was intended to be used for the subsequent dismantling of the scaffold or associated works (eg removal of strapping), even though some of the wording used in the method statement alluded to this.

In the absence of any direction by site supervisory or management staff or knowledge of the access arrangement identified in the original method statement, the panel concluded that the COSS therefore determined to cross the line with his group, in a way he believed was in accordance with the then existing rules and regulation in order to access the site of work. There is evidence of poor safety culture following or condoning customs and practice, rather than an insistence on following or amending the method statement to cover the planned new activity and lack of appreciation by all concerned of the risk of not using the safest method of accessing the work site that would avoid the need for staff to cross the lines at all.

However, the panel was unable to conclude with any certainty what all underlying causes may have been because of the fatality to the lookout and the unavailability of the COSS.

Recommendations

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

• A human factors study to be undertaken to establish the rule books dependence on subjective assessment of distances for safety critical work as a basis for establishing safe systems at work. Possible alternative methods of judging distances should be considered for the future, based on the findings.
• With regards to red zone work-time criteria should be applied based on sunset and sunrise for the day, and location for work. Acceptable arrangements for crossing lines and working at night should be included in the Rule Book. Other factors may still need COSS judgement; this may require more restrictive arrangements to apply.
• A process of briefing method statement elements, relevant to a COSS should be designed and implemented. Where verbal, by an experienced COSS or in a written form.
• The Rule Book should specifically require lookouts stand in a position of safety.

Rail Safety and Standards Board 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. Rail Safety and Standards Board will track the industry's response to this report.