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Blinded by the light

We all make mistakes. Almost 11 million people voted Conservative at the last general election; just look how that turned out! Prompted by the scourge of fee-waiving lawyers, for the past 15 years companies have endeavoured to make the workforce behaviourally perfect by imposing ever-tighter bureaucratic and procedural controls, an approach supported by regulators. Its resounding failure comes as no surprise to anyone blessed with sense, which explains why our industry’s safety leaders continue blindly down the same path. An unwillingness to reconcile themselves with the truth about erring humans imposes a hefty toll in terms of the time and money invested. Trouble is, the alternative - pragmatism - is also quite expensive thanks to the erosion of personal responsibility brought by the social cancer of the compensation culture.

The Rail Accident Investigation Branch (RAIB) often seems devoid of reason when it comes to analysing the causes of mistakes. I’m convinced investigators just feed numbers into their laptop and then wait for it to tell them what to think. Conclusions feel binary: precious little brain power involved, let alone much appreciation of human factors. Which probably explains why the Branch felt unable to launch a full inquiry into the potentially fatal events at Four Lane Ends crossing in September last year, caused by a single momentary lapse. The evidence probably prompted a blue screen of death; smoke belching from the USB ports. The judgement: “unable to compute”.

As cock-ups go, this one was classic; a conspiracy of circumstance that no keypoint card, procedural gloop or high-level platitude could have averted. It demonstrates the futility of the safety professional's focus on all things fluffy and irrelevant. What would have helped was a practical safeguard to prevent an instinctive response becoming lethal, but of course such things are not in the armoury of the suit-laden committees established to determine how life will be lived on the front line. If it can’t be risk-modelled and data-crunched, it can’t be of any value; danger will follow if the bullet point count is too low or the form too flimsy.

As its name suggests, Four Lane Ends crossing sits astride a junction where four minor roads meet, a little over a mile east of Burscough Bridge Station on the Wigan-Southport line. Until 1971, it was protected by gates operated by the road user; thereafter hydraulic barriers and miniature stop lights were installed. This arrangement involved the operation of a lever to pump up the barriers if the lights were green. From 1989, in response to increasing road traffic, British Rail provided a crossing keeper to perform this function.

Seven years ago the life-expired system was replaced with electrically-powered barriers operated by one of two switches - one found in the crossing keeper’s cabin and the other close to the north-side barrier machine. These switches were not interlocked with the protecting signals, making it unusual for a crossing of this type on the heavy rail network. Following an incident in March 2011, Network Rail introduced a new control panel, incorporating an audible alarm and lights which confirmed the indication of the miniature stop lights.

Four Lane Ends crossing, viewed from the south side.
Photo: Alexander P Kapp (taken from Geograph and used under Creative Commons licence)

At about 18:20hrs on the evening of Friday 28th September 2012, a car drove up to the crossing from the south side and stopped. A red light was showing due to the approach of a Manchester Airport-Southport train on the Down Main, nearest the vehicle. Comprising Class 156 and Class 142 units, it was heading towards Four Lane Ends at 65mph. However, before it had passed, the barriers went up and the unsuspecting motorist - not unreasonably - took this as a cue to proceed. With doom impending, the vigilant train driver applied the emergency brake and sounded the horn as the car moved onto the line ahead of him. A collision was only narrowly averted.

The crossing keeper had been trained and deemed competent to undertake his role in November 2006, and subsequently passed annual e-learning courses which resulted in the issuing of an authority to work at Four Lane Ends. But at that crucial moment his attention had been diverted by the misfortune of spilling a hot drink over the cabin’s computer keyboard. On seeing the waiting car, he automatically hit the button to raise the barriers without first checking the indication. Easily gone given the circumstances.

Thanks to an intervention from the Knee-Jerk Response Department, the crossing has since been closed pending its upgrading to fully automated operation with obstacle detection - a configuration stipulated by the Gold Plating Review Committee. This is scheduled for completion next month. In the meantime, locals will no doubt relish the opportunity to spend more time in their cars burning fuel as they explore the delights of the imposed diversion.

With level crossings, you can engineer mechanisms to remove people from the chain (having first waited for a near-fatal accident to occur, of course); with on-track work, it’s not so easy. However good technology gets, it will never make the experienced man’s insight redundant. Too many tragedies have proven that, and recent near misses have demonstrated the recklessness of deep staff cuts. We need eyes and ears out there in sensible numbers.
However good technology gets, it will never make the experienced man’s insight redundant.

RAIB is too short-sighted to see it, but Four Lane Ends was a big deal. Painted high in red letters is its recommendation…not directed at the practitioner, but at the safety gurus. Forget your research into incident factor classification systems; forget that best practice guide you were trialling with a focus group; forget the amendment to GC/RT5033 on the provision of end impact walls. All this is just commentary; peripheral trivia that gets washed away with a spilt cup of coffee.

One card trumps everything: human fallibility. In a trackworker context, the only way to minimise its impact - if it can’t be eliminated - is through the implementation of real safeguards. One safe cess is worth a million Rimini packs; an additional pair of eyes sees the next train sooner; empowering the competent to exercise their knowledge - rather than deferring decisions to the office-bound - makes safety more robust. But this stuff is difficult and dirty, and only the brave embrace it. Given the prevailing culture, what are the chances on today’s railway?

On 8th March, two S&T technicians were taking part in track renewals work between the platforms at Hope Station, examining cables from the four-foot of the Up line whilst tamping took place on the Down. An RRV then approached them, apparently without warning, causing one of the men to dive clear and trapping the other between the RRV’s caterpillar tracks and the platform copings. He was taken to hospital but released later with bruising to his leg and ankle.

Given the fatal potential of this accident, you’d like to think RAIB might have taken an interest. But its 23-strong Inspectorate - each enjoying salaries of around £70,000 - are clearly up against it having commissioned 23 inquiries during 2012. That’s one each! Of these, five have already exceeded the 12-month statutory time limit for publication. Another, from September 2011, still hasn’t been finalised 18 months after the event. Having improved a little in 2011 by starting fewer investigations, the Branch’s performance is worsening again. Not that this will have any consequence - highly-paid public servants rarely suffer sanctions when they fail in their duties and obligations.

Network Rail paid a relatively small price for the life-changing injuries sustained by Terence Wray during track work at Cheshunt Junction in March 2010. St Albans Crown Court recently heard that the maintenance work he was participating in had been inadequately planned by unqualified staff, placing Mr Wray in unnecessary danger. Having moved to what he thought was a position of safety, he was struck by a train that crossed onto the line on which he was standing, resulting in multiple fractures and deep lacerations. The firm was fined £100,000 and ordered to pay costs of £25,000. Mr Wray has since retired.

Story added April 2013

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