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When will we ever learn?

Although the installation of TPWS (Train Protection & Warning System) has made a substantial dent in the Category A SPAD statistics, the numbers have not been looking quite so rosy when it comes to movements within T3s. Over the past two years, several engineering trains, OTP and OTMs have passed the signal protecting CCTV level crossings at danger, without the correct authority. No doubt this has been brought to the attention of an enforcement authority as Network Rail was recently prompted to issue a missive on the subject.

Several causes have been identified. Amongst them, poor communications resulting in a failure to reach a clear understanding, assumptions being made on the operation of the relevant crossing and confusion over the rules set out in module T11. Staff are being reminded of its contents.

It is fair to assume that those involved in controlling and authorising such movements are not all inherently stupid, which might point to the rules themselves being less than helpful. Regular visitors to this ranting portal will already see where I’m heading. If the workforce has been deemed competent and yet incidents are regularly occurring, does the problem lie with the people or the rules they are expected to apply? Do those instructions - written and developed in comfy office suites - meet the needs of their audience and work to their strengths?

So I was naively expecting to learn of a T11 review when I doubled-clicked on the new-look Information Bulletin recently posted by RSSB. It’s their first for eight months and has presumably been triggered by the end of the company’s traditional winter, spring and summer period of suspended animation.

The lead story alerted the world to its recent relocation to an office block at Angel boasting several conference rooms, some of which can accommodate 80-90 people ‘theatre style’. I wonder if they're hosting a pantomime this Christmas? On 11th June, 34 senior representatives from across the railway decided that they had nothing better to do that day so an Industry Safety Meeting was held there. Judging by the photograph, it looked a thrilling and rip-snorting affair. I only hope the extractor fans were working.

I wonder if they're hosting a pantomime this Christmas?

(A quick message to RSSB’s designer: you need to synchronise your colour profile settings before exporting the design file as a PDF.)

But there was no mention of T11 or any other rules for that matter - they must all be in perfect working order. There was though news of the Station Safety Research Guide (which will undoubtedly recommend that passengers do not perform high-wire acts along the OLE), an online Community Safety Resource Centre and the inevitable Events Guide which was always a highlight of the old-style bulletins. Book your tickets now for the ‘Defect reporting and corrective action system seminar’. You just couldn’t make it up!

Meantime, back in the world of railway safety, another of my favourite organisations (and there are so many to choose from) has just published its findings into an accident on the East Coast Main Line at Stevenage in which a trackworker sustained injuries after an encounter with a train. In fairness to its authors, RAIB, this one appeared in super-quick time, taking less than nine months. No really, that’s lightning fast by its standards.

At 1735 on 7th December 2008, the man involved was participating in the renewal of the Up Fast line which, along with the Down Fast, was under possession. These blocked lines occupied the centre of the formation with the Slows running either side of them. To allow work to continue in darkness, temporary lighting was shining brightly from the Up cess.
Looking south from the sleeper ends of the Up Fast line, with the open Up Slow to its left.

Picture Source: RAIB Rail Accident Report (Crown Copyright)

Supposedly protecting those on site was a separated green zone. However, despite the fact that work had to take place within 3 metres (10 feet) of the open Up Slow, no site warden had been appointed. This was contrary to the rules. There was though an ATWS to warn machine controllers of a train approaching on the Up Slow, prompting them to confirm that their machine’s load was not obstructing the line. The system was also being used in lieu of a site warden, creating a hybrid safe system.

At around 1730, the workgroup became separated as they dealt with a series of movements within the worksite. The soon-to-be-injured man had to stand clear of a new length of rail which was being positioned by Trac Rail Transposers (TRTs). With others, he found himself in no man’s land between the blocked Up Fast and its open neighbour on which a 20mph TSR had been applied.

The ATWS then activated and work stopped as a precaution. The driver of the approaching train sounded the horn intermittently but his train’s presence plunged the site into darkness as it passed between the worksite and the lighting, which had been moved into the cess earlier in the day due to its instability. Unaware that the TRTs had stopped working and concerned that a rail might swing and hit him, the casualty turned to check his clearance from the train; as he did so, he came into contact with it and fell to the ground.

As is the case at many hundreds of similar worksites, the red/green concept does not fit with situations involving work on a blocked line, close to an open one. As a result, the safe system at Stevenage was dogged by confusion as to what was actually required. This was perpetuated by the planners’ paperwork - the Task Briefing Sheet - and their failure to book any site wardens, reinforced by the Engineering Supervisor’s silence and errantly established as a grey area by the COSS. Incidentally, whilst operational, the Trac Rail Transposers are meant to be surrounded by a sterile area extending 5 metres at all sides. Consideration of this would have absolutely ruled out any form of green zone working but nobody knew about it.
A Trac Rail transposer in action.

Picture Source: RAIB Rail Accident Report (Crown Copyright)

The inquiry claims that “a site warden would almost certainly have noticed if anyone moved outside the Separated Green Zone and instructed him to move back into it. That would have prevented the track worker standing where he would come into contact with a passing train”. This statement is nonsense and demonstrates a lack of on-track understanding. A site warden can prevent nothing, only warn. Their effectiveness hangs or falls firstly on the site warden choosing to issue a warning (which they often don't if the movement being made has some reason behind it) and, secondly, on the straying person taking action to reposition themselves within the protected area. They might or might not comply; they can’t comply if the movement they are making out of the green zone is uncontrolled - a slip, trip or fall.

The failure of red and green to deal effectively with such situations triggered much debate on the Track Safety Strategy Group, particularly amongst members of its Rules Simplification Subgroup. Indeed it developed a simple two-level strategy to address this specific scenario, one which attracted support until Network Rail sat on it. Following publication of its report into the trackworker injury near Victoria - reviewed on this site last month - I alerted RAIB to this workstream along with three others. The branch has not even acknowledged my email.

With more tragic consequences, a very similar event occurred at Acton Main Line in June 2005. That was the subject of an independent inquiry chaired by railway-wise William Hill, to which I contributed. It recommended that the use of site wardens at track renewals sites be reviewed, with fencing mandated wherever practical. Also suggested was a booklet aimed at planners and site managers, shattering myths about red and green zone working. I developed the booklet and work on it was substantially complete when, again, Network Rail had a change of heart. If you’re interested in seeing it or perhaps even progressing it for eventual use, drop me an email and I'll send you a copy.

The point is that here was a known issue, one which had previously had appalling consequences for one member of the railway community. But had we learned the lessons? What had been done to prevent recurrence?

At Stevenage, the absence of a fence was deemed to be a causal factor, exacerbated by inadequate planning processes. RAIB recommends that Network Rail review the rules governing the use of fences alongside tracks open at linespeed. I can almost hear Bill Hill uttering “I told you so” from his Norfolk pulpit.

Yet again, a managerial failure to energetically learn lessons and act following one tragic event almost allowed another to occur. It is only by good fortune that the consequences on this occasion were rather less terminal.

Story added 1st October 2009

RAIB: Trackworker struck by train at Stevenage
Link to RAIB's Stevenage inquiry page, from where you can download a full copy of the report.

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