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Mission impossible

They’re big, with bright headlights and cause the track to ‘ring’. They travel in predictable directions. Their drivers sound reassuring toots when they see you. On the face of it then, it shouldn’t be difficult to remain unscathed by passing trains. But what if there are too many of them, delaying the work? What if they take an age to reach you or stop on their approach? What if they are diverted from their usual route? What if your mind is elsewhere? This was the conspiracy of circumstance that left a track chargeman unknowingly standing in the path of a train, with his back to it. The fact that he is still alive also owes much to fate.

The fact that he is still alive also owes much to fate.

On 30th March 2010, a gang comprising four Network Rail employees - including the chargeman and a COSS - and four agency workers from TES 2000 were assigned two maintenance tasks on the line from Liverpool Street to Cambridge. The chargeman had risen to that grade in June 2006, having joined the industry in 2001. The COSS had held his competency for six years and been a railwayman for seven.

At around 07:30hrs, a single Rimini pack detailing the protection arrangements at both sites was handed to the chargeman by Tottenham depot’s track section manager and the gang headed off to undertake their first task - to pack ballast beneath a joint in the plain line section between Angel Road and Ponders End stations. On arrival at the access, the COSS briefed the team on the safe system - involving red zone working - and each member signed his form. The work was completed at about 10:00hrs and they piled back into their vans for the journey to the second location at Cheshunt Junction. The chargeman’s agitation at their slow progress was apparent.

When the TES workers arrived, the COSS had already appointed two of his Network Rail colleagues as lookouts - one positioned adjacent to the Up Cambridge line, close to the diamond crossing beneath which they would be packing ballast, and a distant man next to the Up Southbury. The lookouts were apparently told the position of safety - in the cess alongside the Down Southbury - but the TES workers were not. No amendments were made to the paperwork to take account of the new location and its more complex track layout.

The sighting distance of Up trains, approaching from Cambridge, was about two miles, considerably more than was needed to provide the required warning time with a linespeed of 80mph. Moreover, Cheshunt Station sat between the site and the point at which trains first came into view. A similar situation applied in the Down direction, with Waltham Abbey Station located a mile south of the site. The view through it extended for a further mile.

In force at the time was Rule Book Module T6. Clause 7.6b required site lookouts to “immediately give a warning to the group” when they “see a train approaching”. Unusually for the Rule Book, this seems clear and unequivocal. However RSSB staff have a different interpretation, apparently telling RAIB’s inquiry team that the warning should only be given when the train passes a point identified by the COSS. Of course, no written guidance has been produced to that effect. In any case, how practical is it to accurately determine the position of a train on a straight piece of track when the view of it is entirely head-on? Characteristic RSSB nonsense.

Cheshunt Junction is a very busy place. Following the accident, RAIB monitored movements there for a period of one hour on a weekday morning. 22 trains passed through - the shortest approach lasting 52 seconds and the longest, involving a prolonged stop at Waltham Cross, taking more than five minutes. All lines were clear for a total of 24 minutes, with no trains visible for periods ranging from 27 seconds to almost five minutes. Had compliance with the rules been meticulous, it’s likely that the gang would have retreated to their position of safety on 13 occasions during that hour, sometimes staying there whilst two trains went by.

So this was the background against which the work was taking place. No surprise then that the chargeman expressed his concern about the delays being caused by passing trains, prompting him and the COSS to remain in the four-foot of the Down Cambridge on at least one occasion as a train scuttled past on the Up. Witness accounts suggest the chargeman was also preoccupied by an issue with his managers, one he was keen to resolve that day back at the depot.

Demonstrating the excellent sighting distance, this is the view south through the junction towards Waltham Abbey Station. Approaching is a service on the Down Cambridge.

Photo © Normal for Norfolk

2B13 - a Stansted Airport to Liverpool Street service - appeared into the site lookout’s view at 11:03hrs. He sounded a warning. As it slowed to stop at Cheshunt, forward-facing CCTV captured two gang members with the lookout in the Up cess and four more standing on or close to the Down Cambridge. The lookout advised that the train was stopping, allowing two of them - including the chargeman - to continue working.

Whilst they had been on site, all London-bound trains departing Cheshunt had continued on the Up Cambridge. None had crossed to the Up Southbury. Down services from the Southbury loop had entered Platform 3 via the bay line which was 17 feet from the diamond crossing. And this was the pattern of movements encountered by the chargeman and COSS on previous visits there. But things were different on this occasion. Unbeknown to those in the four-foot, work further up the line at Stratford had brought capacity constraints, meaning that one train per hour had been running into Liverpool Street via the Southbury loop for the previous five weeks.

2B13 stood at the platform for 25 seconds. As it moved off, the train’s horn was sounded - this was acknowledged by some group members - and the lookout repeated his warning. The driver determined that those men still in the four-foot of the Down Cambridge were clear of the diamond crossing and he accelerated his unit to 30mph, the maximum speed for the junction onto the loop. As it passed over the crossing, the train hit the chargeman who was standing with his back to it in the six-foot. He was thrown clear, sustaining serious injuries.

The COSS attempted to call Liverpool Street IECC via a signal post telephone, but it wasn’t working. Instead he had to use his mobile. All lines at the site were blocked while the emergency services attended to the casualty. Unaware of the incident, the driver took his unit all the way to Liverpool Street.

The view towards Cheshunt Station from the junction.

Picture Source: RAIB Rail Accident Report (Crown Copyright)

The inquiry accepted that red zone working was the only practical option for daytime maintenance at such a busy location, but found this reality to be a causal factor in the accident. So too was the gang’s assumption that the train would proceed via the Up Cambridge. RAIB regards the site lookout’s non-issuing of an urgent warning when some group members stayed in the four-foot of the Down Cambridge as a possible causal factor, along with the COSS’s failure to formally identify a position of safety.

Whilst recognising that the lack of a separate COSS form for Cheshunt meant that gang members could not sign for a site-specific briefing - and therefore one wasn’t given - RAIB is critical of them for not complying with the fundamental need to move to a safe place, clear of all tracks on which a train might run. The Branch clearly discounts - or perhaps didn’t even consider - the impact of peer pressure on their actions. “The chargeman…had a general responsibility for the behaviour of his team and should have intervened to prevent unsafe actions” says the report, ignoring the fact that he might have been driving those actions through his agitated state.

Amongst the underlying factors was the quality of the planning. This did not take into account the higher risk levels associated with work at Cheshunt Junction where movements are made in several different directions. An automatic warning system would, claims RAIB, “have increased the amount of time available for work without increasing the level of risk”. But this would only apply if it interfaced with the signalling so that warnings were issued dependent on the route that was set. And even then, the presence of a station in the Up direction so close to the junction would result in excessively early warnings. That would probably have driven the gang to act as they did when lookouts were used. The benefit of a human protection is the ability to make judgements based on the events being played out in front of you; you can’t do that with a machine. So RAIB is showing its ignorance here.

The Branch recommends that Network Rail assesses the hazards and risk at every junction where lookout protection is currently permitted so that a set of predefined safe systems are established that take local factors into account. Quite what difference this would have made is anyone’s guess - the gang’s approach was prompted by the high traffic flows and, probably, the chargeman’s agitation. NR should also evaluate the behaviour of staff working at locations with extended sighting distances. So that’ll involve more money being flushed down RSSB’s research toilet, no doubt.

The view towards the diamond crossing from the disused signal box.

Picture Source: RAIB Rail Accident Report (Crown Copyright)

This was yet another event with human factors at its heart. The one-size-fits-all rules - if implemented as written rather than how RSSB silently believed they should be applied - forced the gang to spend an unsustainable amount of time in the cess. As a result, the COSS and chargeman felt driven towards [alleged] non-compliances - and RAIB damns them for that.

In many respects, the Rimini planning regime is really the trouble-causer. Instead of the safe system being determined by the person implementing it on site (as HSE track safety principles say that it should be), that responsibility has been devolved to folk who sometimes lack much-needed practical experience. That becomes a problem at places like Cheshunt. And there has been a consequential decline in the ability of COSSs to properly analyse the suitability of safe systems and understand what’s needed to make them robust. They’ve lost that discipline through lack of use.

The chargeman is expected to make a full recovery from his injuries, but remains off work.

As a footnote to this, I think it’s worth quoting a post from an online railway forum. “I recently had an interview with an RAIB investigator” writes one contributor, “and was shocked about how little they knew/understood about ‘real’ railway”. Sadly this truth is all too apparent from many of the Branch’s reports and it’s something that really needs addressing.

Story added 1st May 2011

RAIB: Accident at Cheshunt Junction
Link to RAIB's Cheshunt inquiry page, from where you can download a full copy of the report.

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