First things first - the events of Tuesday 4th December 2012. Scott and his gang of five were assigned to carry out track maintenance duties on the Down line at Saxilby - between Doncaster and Lincoln - following replacement of a waybeam at Sykes Lane bridge over the previous weekend. Engaged by SkyBlue, they were working for Carillion on the Great Northern/Great Eastern (GN/GE) project, as a result of which a Carillion track quality supervisor was also in attendance. Collectively their experience was extensive, having worked in the industry from six months to 25 years. Scott had been on-track since 2006, qualifying as a COSS two years later.

That day’s safe system of work pack - produced by a Carillion planner - went down the green zone path, identifying the need for blockages of both lines due to the likelihood that members of the group would occasionally need to position themselves in the six-foot. Though not heavily trafficked, line blockages on the route are only available for relatively short periods. Safeguarded green zone working (all lines blocked) is not a practical proposition for more than a few minutes at a time. Consequently the planner had allowed four days for the tasks to be completed, with five more set aside the following week as a contingency. And we wonder why the costs and timescales associated with infrastructure works are so ridiculous. 'Inefficient' doesn't come close.

Having been diverted to another job, the gang arrived on site sometime after 11:00hrs. Scott then called the box to start negotiations for a line blockage - the first of several conversations he had with the signaller that morning. A little while later, the signaller rang back to ask if he’d be willing to work under the protection of another COSS working nearby who had already been granted a blockage. This was agreed and removal of a twist fault on the cess rail of the Down line got underway at 12:43hrs, with the adjacent Up line still open to movements. Scott, acting as COSS, also assumed the role of Site Warden.

The blockage was given up 26 minutes later to allow a train to pass. As it did so, Scott and a colleague - standing in the Up cess - observed voids beneath the track. Resolving this defect would require one member of the gang to work with a pneumatic hammer between the two tracks. The inquiry report asserts that for this to be carried out in accordance with the Rule Book, both lines would have to be blocked. This of course is incorrect: a red zone could have been established using the blocked Down line as a position of safety.

When the other COSS, acting as Protection Controller, rang Saxilby box to retake the blockage at 13:44hrs, Scott had not made him aware that the next phase of work would require access to the six-foot. As the gang began labouring with their noisy hammers and shovels, at least two of them were standing beyond the site’s theoretical safe limit. One was Scott. He had not established any method of protection to deal with passing trains on the adjacent open line and, probably as a result of that, neither had he provided any formal briefing. No-one in the group challenged this, but that’s trackworkers for you: they keep their mouths shut, make do and get on with it, fearful that creating a fuss might compromise the job and their future employment prospects. It can be assumed that Scott intended to act as unofficial lookout; sighting in the Doncaster direction was excellent for that purpose.

What happened next is a matter of some uncertainty. It seems likely that Scott either became distracted by the work or chose to take part in it. But six minutes after grafting resumed, a Scunthorpe to Lincoln train approached unnoticed on the Up. The horn was sounded as it made progress towards another group standing in the adjacent cess, 250 metres in advance of Scott’s. After passing them, two more blasts were given, eliciting at least one acknowledgement from the track maintenance men. The driver then refocused his attention onto a signal. Still oblivious to the train, Scott stepped backwards into its path and was struck side-on, sustaining fatal injuries. Although not wearing ear defenders, we must presume that a combination of work and wind noise effectively drowned out the train.

The inquiry report is silent on a number of key issues relating to the protection:

• Did the planner request blockages of both lines - potentially for nine days - through the GZAC process and, if so, was that request accepted? If not, why was Scott given the plan? If so, how could the system approve an application that was clearly untenable?
• Given the nature/duration of the activity and limited opportunities for line blockages, what was the decision-making process that resulted in the choice of safeguarded green zone working? Was it genuinely deemed a realistic possibility or specified in order to tick the most managerially desirable box and therefore enhance the project’s red/green statistics? In other words, was it incompetence or conspiracy that compelled Scott to pursue a safe system which had no prospect of being implemented?
• Why was use of an automatic track warning system (ATWS) not considered, as this would have delivered a safer site and significantly improved productivity? (Answer: because an unworkable green zone option had already been selected.)
• Why was it not identified at the planning stage that another group would be working at the same place at the same time such that their collective protection needs could be established and arranged, rather than compelling those involved to cobble something together on the day?
• Was Scott under the errant impression - as most COSSs are - that having blocked a line, his only legitimate course of action was to appoint a Site Warden to mitigate the risk from passing trains, irrespective of whether the work required access into the six-foot? In other words, did he consider himself to be in a procedural vacuum with no alternative but to work beyond the rules? (That’s obviously a difficult one to answer but other gang members might have been able to provide some insight on the basis of his past actions in similar situations.)
• Why does RAIB’s investigator perpetuate the above myth by asserting that looking out for trains in such a situation would be “informal and prohibited by the rule book”, and then compounds that error by incorrectly stating that “Persons working in the six-foot were closer than two metres to the open up line (which is not permitted by Handbook 7 of the rule book).... For the work being carried out, both lines should have been blocked”? What a fabulous head-in-the-sand statement. That approach had already been deemed impractical and in fact was not the only valid option available.
• Did RAIB ever stand back and ask the bigger question: is a hierarchy of protection methods really fit for purpose when it does not substantively acknowledge the benefits of providing a warning of approaching trains when work is taking place on a blocked line alongside an open one? Indeed, by not facilitating this, does it systemically drive the adoption of safe systems that expose trackworkers to greater risk? Oh yes.

I don’t expect answers to these questions as RAIB clearly doesn’t understand their pertinence. Hopefully though the lawyers acting for Scott’s family will seek them out. The Branch’s four recommendations miss all the vital issues and are generally predicated on the presumption that those hired by labour agencies have an inherently poorer culture and lower level of competence than those working for Network Rail and its principal contractors. Whilst there is undoubtedly rumour and innuendo to that effort, inquiry recommendations should be founded on facts. Where are they? The real problem is more general: the structural mechanisms in place to manage all workers within the industry are too complex - resulting in their occasional failure - overly burdensome and bureaucratic, and as a result lip-service is often paid to them. The can of worm Scott had become embroiled in - outlined below - was beyond farcical.

Two months before the Saxilby accident, Scott played the pivotal role in a serious close call near Clay Cross whilst hired out to AmeyColas. Acting as Protection Controller, he instructed a handsignaller to lift detonators protecting a line blockage without first establishing his exact whereabouts. As a result Scott advised the signaller that the line was clear before the handsignaller had even arrived at the dets. As he was lifting the first one, a train approached and he had to jump clear.

The following day, Network Rail’s Production Manager for the project contacted SkyBlue’s Rail Manager to request the immediate suspension of Scott’s safety-critical qualifications. This was acknowledged and arrangements made to speak to Scott who was also asked to give evidence to a preliminary investigation into the incident. Based on his conduct at that meeting, both the AmeyColas and SkyBlue managers apparently expressed concern about his attitude and unwillingness to recognise that his actions had been contributory.

AmeyColas believed that the agreed outcome was the temporary suspension of Scott’s competencies, pending the investigation’s outcome. SkyBlue’s Rail Delivery Manager would take the lead in coordinating the necessary actions, assigning the task to the company’s Rail Manager. However he neither withdrew Scott’s Sentinel card nor applied for it to be suspended. He did not advise the Rail Delivery Manager of this. A number of factors potentially gave rise to this, notably that Scott was a personal friend of the Rail Manager and performed a vital role in organising the track gang’s activities. Losing him could have had a detrimental impact on the GN/GE project.

A month after this incident, Scott was involved in another. Again he was working for AmeyColas, this time appointed as COSS on a site at Clay Mills. In light of the events at Clay Cross, the firm had made an entry in its site access database to exclude Scott from its sites. However this database was not always checked, allowing him to gain access at Clay Mills effectively without authority.

A failure of the planning process meant that no-one had been allocated to perform the role of attendant at a level crossing, so Scott volunteered. He took the crossing under local control and a tamper was authorised to cross. Its technician then allegedly advised Scott that the tamper would not be returning that way. However a short time later it did so with Scott absent, passing the protecting signal at danger and approaching the crossing whilst the barriers were still raised.

Network Rail launched an investigation and Scott was asked to attend a panel meeting. He refused to do so or provide a statement. He also advised SkyBlue that he would not accept any further placements on AmeyColas sites. During the panel meeting it became clear that Scott had been involved in both this incident and the one at Clay Cross, but this did not prompt any enquiry as to why his certification had not been withdrawn. Network Rail managers considered taking direct action to suspend Scott’s qualifications but chose to leave things to AmeyColas as they assumed the company was following matters up with SkyBlue. This again led to no action being taken.

SkyBlue’s Rail Manager left his post on 16th November, 12 days after Clay Mills. No formal handover took place with his temporary replacement - who had no railway experience - or the firm’s Regional Manager. On the same day, the Clay Cross investigation report was sent to the Rail Delivery Manager. This made the formal recommendation that Scott’s COSS certification should be immediately suspended and AmeyColas signed this off as closed, presuming it would be acted upon. However the email was not opened until after Scott’s death, more than two weeks later. As a result he continued to perform safety-critical duties on a regular basis, acting as COSS on 35 occasions over the two months between the Clay Cross incident on 4th October and his passing at Saxilby on 4th December.

The inquiry found that SkyBlue had no process in place to ensure all events involving its staff were reported and recorded; neither were there clear lines of responsibility for managing any follow-up actions. As a result, no-one within the company was able to monitor the outcome of the investigations. The Regional Manager knew about both incidents but not that the same person was implicated.

It was the job of the firm’s Rail Manager to address any competence deficiencies amongst those it hired by establishing a programme of coaching, instruction and mentoring. However he did not have the necessary knowledge and experience to assess the performance of anyone acting in safety-critical roles such as COSS. So there was no reliable mechanism whereby any shortfalls in Scott’s behaviour could be identified and addressed.

More broadly, as casual workers are often on the books of several labour agencies simultaneously, the connection they have with each company is much weaker than those between staff members and their employers. This creates a muddying of responsibilities in terms of competence management/development, investigations and disciplinary action. It should however be noted that the creation of a Primary Sponsor role through New Sentinel will go some way to addressing this.

Finally, let’s take a moment to despair at this powerful demonstration of just how superficial and valueless most health and safety bureaucracy is. Carillion’s risk assessment procedure - known by the snappy title PLC/CORE/HSSQ/PRO/082 - required their on-site track quality supervisor to complete and brief a point-of-work risk assessment form for every task undertaken. This piece of paper (reference number RAIL/HSSQ/PRO/082-F008) comprised a series of 14 questions and tick-boxes, amongst which was “Has everyone in the gang received SSOW briefing (is it correct & fully understood)?”

There was no sign of this document on the day of Scott’s death; indeed the supervisor had never previously submitted one during his time on the GN/GE project. But that’s not the big deal here. An internal review found that not only had other Carillion supervisors routinely failed to complete these forms, the company had not thought to audit them. Clearly, without identification of this non-compliance, no action could be taken to resolve it. The requirement to fill the form in had been documented in a procedure, put on a shelf and forgotten about. And there is nothing to suggest this culture is unique to Carillion. You can rest assured that an aversion to paperwork manifests itself at the frontline of every company active on the infrastructure. This reflects the reality that bureaucracy is mostly developed to keep the Regulator happy and a surfeit of middle managers ungainfully employed; it fulfils little practical purpose.

Bob Crow’s default response to any issue - no matter how inconsequential - is to attach solid rocket boosters to it. This time, there is mostly truth in his hyperbole. He asserts that the dangers faced by trackworkers are “compounded by the use of contractors and agencies and the growth of zero hours contracts and casualisation in this safety-critical environment.” He goes on, “In this case the victim of this tragedy was on the books of SkyBlue, working for Carillion and several steps away from the actual organisation responsible for rail infrastructure, Network Rail. That chaotic approach has to end with Network Rail taking over these contracted staff under central control on decent pay and conditions.”

Being popular and likeable are not essential attributes for a COSS. They must however command the respect of their subordinates and it’s clear that Scott Dobson had earned that. When COSS Beverly Swane was found not guilty of manslaughter after one of his men, Mark Falivena, stepped out of a green zone and into the path of a train at Desborough in August 2001, Mr Justice Harrison asserted that Swane had “in no way acted outside the accepted standards of the industry. The overwhelming evidence…is that many workers would have done the job in the same way.” Whatever his flaws, my instinct is that this statement could equally apply to Scott.

...many workers would have done the job in the same way.

The inquiry report makes difficult reading but, as is too often the case, RAIB focusses its attention in the wrong places. Yes, there was a paralysing breakdown of the safety management system; yes, that desperately needs dismantling and made more effective; yes, there are too many interfaces, blurring lines of command. But that really is a side show. If engrained into Scott’s mind was the need to provide a warning of trains passing on adjacent lines - and the relevant Standards had captured, encouraged and facilitated that - he would still be alive today, irrespective of the structural collapse that allowed him to act as COSS. And unlike Desborough, there were no practical barriers to the use of a lookout at Saxilby.

Safety professionals - through their arrogance or ignorance - laid the foundations for Scott’s death, just as they did with Mark Falivena 11 years before. They chose not to learn the lessons from that previous tragedy and should be called to account for that. Driven only by dogma, they have relentlessly promoted a method of protection which anyone with vision knows is flawed, fatally so. They won’t change their minds voluntarily - that would involve an acceptance that they’ve been wrong all along - and no-one should have faith in a Regulator that has supported them in their delusion. What’s needed here is a huge kick up the corporate arse from the legal system. My fervent hope is that there’s a rugby-playing lawyer out there with a pair of size 12 steel-toed boots. The industry must be persuaded to instigate change.