Formal Inquiries

Oakley report and recommendations

Rail Safety and Standards Board (RSSB) has issued its formal inquiry report into the circumstances surrounding the death of a track worker following contact with a 750V conductor rail at Oakley on 7 August 2003.

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 0933hrs on Thursday 07 August 2003 the driver of the Bournemouth to Aberdeen service reported seeing a person lying across the conductor rail of the Down line at Oakley. The deceased was an employee of an agency. He had been acting as lookout for a group of electric track maintenance staff working on the conductor rail.

Conclusions

The formal inquiry panel concluded that the immediate cause of this accident was the lookout coming into contact with a live conductor rail, due to the work being undertaken in a Red Zone with the conductor rail energised.

The panel also concluded that work was planned in a Red Zone with the conductor rail energised because:

• the location of the work enabled this to happen as only one lookout was required with good visibility in each direction;
• it was custom and practice for this particular type of work to be carried out under these conditions;
• industry guidelines allow routine maintenance tasks to be undertaken in these conditions.

There is evidence to suggest that the lookout was involved to some extent in the physical work activity of the gang and was not solely carrying out lookout duties.

The Panel is unable to determine what drove the lookout to participate in the physical work and the controller of site safety (COSS) to permit him to do so.

Recommendations

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

• Planning processes to enable greater use of Green Zone working.
• Consider the types of work which are permitted to be carried out in close proximity to the live conductor rail.
• For work that is to be done in close proximity to live conductor rail, ensure that there are method statements defining the safe system of work.
• Consider the extent of formal training and possible certification necessary for persons required to work on or near live conductor rails and associated equipment.
• When employees are transferred to new duties, review their training and experience and provide additional briefing, training and competence assessment.
• Ensure that persons required to work adjacent to live equipment are issued with the appropriate personal protective equipment, and know how to check and use it.
• Clarify the wording relating to work within 300mm of a live conductor rail.
• Review system of management safety checks to ensure that all working groups are seen performing work activities.
• Examine whether the emergency equipment provided in Class 221s is best placed for rapid deployment in an emergency.

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.