Rail Safety and Standards Board (RSSB) has issued its formal inquiry report into the circumstances that led to a m ember of workforce being struck and fatally injured by a passenger train at Newbridge Junction near Edinburgh on 5 April 2005.
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
A team of railway engineers had been carrying out inspection work on the Edinburgh to Glasgow mainline. This team was under the protection of a controller of site safety (COSS) and two lookouts provided from a labour supplier. The work was carried out during normal traffic conditions and involved the team moving along the Up side cess towards Newbridge Junction, facing the direction of traffic, whilst taking measurements and making notes relating to the condition of track assets.
None of the work required any of the personnel to leave the Up side of the track. However, as the team neared Newbridge Junction the sounding of a train horn caused the COSS and the inspection team to look up to see the Site Lookout standing on the downside of the line, with his back to traffic. He then almost instantaneously fell to the ground as a train passed onto the Bathgate branch.
At first, none of the staff in the Up Line cess were sure whether the Site Lookout had stumbled or been hit by the train, but when they reached him, it was clear he was seriously injured although, at that stage, still alive. The team leader immediately used his mobile phone to summon the emergency services and the COSS began administering first aid. Sadly, the Site Lookout succumbed to his injuries later whilst being tended by paramedics.
The immediate cause of the Site Lookout being struck from behind by the train was his decision to cross the main line without authority and walk to a location where he stood foul of the Bathgate line.
Underlying Causes
The underlying cause(s) may be one or more of the following:
An erroneous assumption about the route the train was to take.
Lack of awareness of the junction layout and the bi-directional nature of the line on which he was standing.
Attention fixation on traffic heading off the branch.
Pre-occupation or distraction, possibly with the end of the shift nearing.
A low level of attentiveness, due to length of shift, time of day or boredom.
‘Automatic’ acknowledgement of train horns, the failure to turn to face traffic, and the lack of a distinguishing urgency feature to the train horn.
The contractor’s acceptance of poorly specified and inadequately documented work at short notice and allowing the client to determine resource levels.
Failure to: Adequately brief lookouts to ensure a proper understanding in respect of actions to be taken if the established safe system of work required to be varied, establish or reiterate arrangements for re-grouping in the event of unforeseen or unplanned occurrences/situations and maintain a safe system of work until the work was complete.
Inadequate levels of briefing, training, and understanding in the key principles of planning site work.
Lack of clarity over roles and responsibilities between the personnel on site, particularly those relating to planning of the work, and planning of the safe system of work.
Allowance of Red Zone work being booked at short notice, where only sufficient time for minimal advance planning was available.
Contractors being booked for safety purposes, also at very short notice, with no advance work specification and no supporting documentation.
Failure to declare important information such as finish location, egress arrangements etc which would allow the COSS to evaluate the proposed safe system of work.
Interpretation of inspection requirements in such a way as to preclude consideration of other than Red Zone working even when this may have been possible or appropriate.
A complacent approach to planning, which extended from deployment of inexperienced team members with almost no advance briefing or instruction, to the failure to advise the COSS on the day of key information.
No apparent check or audit of actual working practices.
Recommendations
The report makes recommendations for improvements in a number of key areas and these are summarised as follows.
A review of work planning activity, to ensure that:
(i) Staff with work planning roles and responsibilities are properly trained and equipped for the task.
(ii) Only staff with appropriate training and competence undertake work planning activities. - Network Rail
Review and revise the Network Rail Business Process Safety of People Working On or Near the Line to ensure clarity: - Network Rail
Undertake research to establish how lack of local geographic knowledge affects ability to plan effectively and carry out work safely. - RSSB
The requirement that any change to an established safe system of work be discussed with the COSS in advance should be explicitly covered in pre-work COSS briefings. - Network Rail and Contractors
Review rules and standards for Red Zone working, to assess their adequacy and applicability to moving, or ‘rolling’ sites. - RSSB
The provisions of the Rule Book regarding sounding the horn, as a warning to personnel on or near the line, and the precise meaning of the terms used should be clarified. The techniques associated with ‘a series of short urgent danger warnings’ should be defined and incorporated into driver training. - RSSB
RSSB 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. RSSB will track the industry's response to this report.
