The Rail Accident Investigation Branch (RAIB) has published its report into an accident on the West Coast main line (WCML) near the village of Roade, Northamptonshire, in which a track worker was struck by a train and killed.
As previously reported on Rail Insider, the accident took place at around 10:52 on Wednesday 8 April 2020. The track worker, who was the person in charge of the work with responsibilities as controller of site safety (COSS), was walking along a line that was open to traffic and did not look towards the approaching train on hearing its warning horn. The passenger train, travelling at 90mph ((145km/h), struck and fatally injured him.
The man had gone back onto the track after handing back a blockage of the line, which had been taken to isolate the overhead line equipment, a task which, it was later appreciated, did not need to be done every day.
The RAIB was unable to determine with certainty why the track worker decided to walk on the track with no protection, but it is probable he had a purpose in mind and that he believed that no trains were due on the line he was walking along. There is also witness evidence suggesting that he had become habituated to warnings from approaching trains.
The investigation found several factors which possibly led to this situation. The performance monitoring and appraisal arrangements for the track worker were inadequate and did not identify and address issues with compliance with rules, standards and procedures. The system of work in place for the site was inadequate for the work being undertaken and did not specify adequate arrangements to encourage compliance with safety rules, possibly affecting the behaviour of the track worker and others during the project. None of the assurance arrangements in place identified any non-compliant behaviours or the inadequate system of work.
In its report, the RAIB makes two recommendations to AmcoGiffen, relating to monitoring and developing the ongoing competence and performance of its staff and ensuring compliance with its management procedures on new sites of work.
- AmcoGiffen should develop and implement formal performance monitoring and appraisal arrangements for identifying and developing the ongoing safety performance and competence of its work force, at all grades. The procedure should include elements of proactive monitoring of staff performance and competence, identify areas of concern, define development needs and monitor their implementation. Suitable information about staff should be made available to all relevant managers across the business.
- AmcoGiffen should review the management arrangements and resources that are intended to ensure that work is planned, undertaken and reviewed in compliance with its safety management systems, particularly in the early stages of establishing new projects and sites of work. It should implement any changes identified as being necessary to provide adequate assurance of compliance.
One further recommendation was made to Network Rail:
- Network Rail should review and amend the Electrical Safety Delivery programme to confirm that it takes account of the learning from the Roade investigation. In particular, it should consider ways of minimising the need for personnel to access the track, such as remotely operated earthing devices, and improved co-ordination and visibility of key information when planning and taking isolations of electrical traction supply and contact systems.
RAIB also identified two learning points:
- Track workers should only access the track when they are protected by a suitable and sufficient safe system of work that is specific to the task they are undertaking.
- It is important that meaningful independent reviews of safe system of work plans are undertaken by a competent person to check that they are specific, suitable and sufficient for the task intended.