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Delays affect RAIB's service

Reach for the whisky bottle. I am beginning this month’s outburst by quoting edicts from the European Union. Article 19 of its Railway Safety Directive compels member states to unearth the causes of serious accidents on the network with a view to improving safety and averting similar events. Article 23 demands that “The investigating body shall make public the final report in the shortest possible time and normally not later than 12 months after the…occurrence" - a requirement which was subsequently incorporated into The Railways (Accident Investigation & Reporting) Regulations 2005.

On the face of it, 12 months does not seem unduly onerous. Even when our inquiries were lead by RSSB - an organisation not known for the drive of Lewis Hamilton - they generally emerged within six or seven months. Stewardship was transferred to the Rail Accident Investigation Branch (RAIB) late in 2005 so it has had ample time to get fully up to speed. Despite this, those waiting for the conclusions of its probing often have more than a year to wait. Whilst the word “normally” does provide RAIB with a convenient get-out clause, overuse of it raises legitimate questions about the organisation’s management.
Whilst the word “normally” does provide RAIB with a convenient get-out clause, overuse of it raises legitimate questions about the organisation’s management.

So, 13 months and 25 days after a trackworker sustained dreadful injuries at Leatherhead Junction, the silence has been broken by the whys and wherefores; the wider industry can at last learn the lessons. The report surfaced on the same day as RAIB’s definitive commentary on the Grayrigg crash - an inquiry which itself took more than 20 months. To be fair, there was nothing ‘normal’ about that one.

On 29th August 2007, five trackworkers had been tasked with patrolling the Leatherhead to Bookham line, including a junction just south of Leatherhead Station. This coincided with one of Network Rail’s ‘Safety Days’ so accompanying them was an Assistant Track Section Manager (ATSM) who would assess the gang’s compliance with the relevant rules and regs.

The leading trackman took the role of COSS, having held the qualification for a year. He appointed two men as lookouts; the remaining pair carried out the patrol with him. Checks of a crossover were concluded uneventfully; so too the track through the station. With the gang separated into two groups on opposite platforms, the COSS then gave a short briefing about their inspection of the junction.

Positioned in the Down cess, one lookout watched for trains arriving from London; the second stood with the ATSM in the V of the junction, keeping an eye on the two converging, northbound routes. At 0909, a service from Waterloo (2D17) entered the station, prompting the first lookout to sound his horn. Although this was acknowledged, the gang continued to work as they could see that the train was stopping. It remained stationary for 34 seconds.
The driver's view as he approached the junction, with the Bookham lines off to the right.

Picture Source: RAIB Rail Accident Report (Crown Copyright)

On its departure, a second warning was given. The COSS raised his arm and moved into the Up cess. There was also an acknowledgment from the patrolman alongside him - known for being safety conscious - who was tightening bolts on the diamond crossing. This man then shouted “one on” but remained in the six-foot between the Up and Down Bookham lines. He bent down to deal with something.

Travelling just shy of 25mph, the train hit the points. The patrolmen stood up, turning his back on the train. In the cab, the driver heard a thud and applied the emergency brake. The patrolman had been struck on his left shoulder and dragged a short distance down the line, sustaining injuries to his head, back and legs. The impact rendered him unconscious, trapped beneath the fourth carriage’s current collection equipment.

Out of sight 300 yards away, 2D24 approached from Bookham. The COSS spotted it, raising his hands to bring it to a halt. The unit stopped 15 yards past the casualty. Not having the controlling signal box’s number immediately to hand, the ATSM reported the accident to the local control centre. The emergency services attended within quarter of an hour. Although uninjured, the other gang members were badly shaken by what they had just witnessed.
Passengers are escorted from two trains following the accident.

Picture Source: RAIB Rail Accident Report (Crown Copyright)

The area around Leatherhead formed part of the Wimbledon track section, responsibility for which had been transferred to the Feltham Track Maintenance Engineer six months earlier. Wimbledon depot was unsettled - lacking managerial direction - with nine of its 52 posts vacant at the time of the accident. The usual staffing complement for the Leatherhead-Bookham patrol was six - only four were available on this occasion.

An ongoing project had been established to address problems which Network Rail had uncovered in its maintenance management system. This had a bearing on the documentation provided to the gang. The patrol diagram, which had not been signed-off following a revision, was confusing and contained anomalies. The COSS was also given three Briefing Forms to cover the day’s activities as well as a Task Risk Control Sheet and two Line Blockage Forms. Despite containing a wealth of detail, these 14 pages could not easily be digested and lacked vital information about track curvature and restricted sighting.

The COSS had only limited experience of setting up red zones and had received no guidance on the correct positioning of lookouts. He calculated that the required warning time for the patrol as a whole was 20 seconds. With a maximum linespeed of 75mph, 740 yards sighting distance was needed. At the junction, the available sighting distance was considerably less than this - 400 yards for southbound trains, 300 yards for services from Portsmouth and only 120 yards around the Bookham line’s tight curve. Although the actual speeds through the points were 60mph on the Portsmouths and 30mph on the Bookhams, only 8-14 seconds warning time could be guaranteed.
Only 120 yards of sighting distance was available to the lookout watching the Bookham line.

Picture Source: RAIB Rail Accident Report (Crown Copyright)

The inquiry found that red zone working with lookouts was the norm for patrols in the Wimbledon area - no other method had been considered. For Leatherhead Junction, the safe system had been planned by local work schedulers and used many times before. It would only have been reviewed if a COSS had raised an issue with it.

But it was not part of the culture to question such arrangements. The gang assumed that the plan had been properly prepared and, if they followed it, they would be safe. According to RAIB, four lookouts would have been needed to work safely at the junction - manpower which was not available. A red zone prohibition is now in place there, resulting in the implementation of T12 blockages. The report is critical of the stagnation which failed to proactively develop this new regime prior to the accident.

According to RAIB, “action to improve safety for [trackworkers] is urgently required”. It wants to see plain line and S&C inspections separated. Mechanising the former would reduce risk exposure and allow the latter to be planned more carefully with appropriate equipment and lighting, it claims. On lines with continuous welded rail, S&C should only be inspected by specialist staff and always in green zones.

As we have come to expect, this is yet another inquiry to generally pour scorn on red zones, with little logic or perspective. It is however impossible to advocate their use at Leatherhead Junction. But perhaps the reality that screams loudest from the report's pages is the absence of an effective support structure for those exposed to danger. Yes, there was paperwork in abundance; yes, their ATSM had a watching brief; but who was acting as the experienced guiding light?

As a footnote, I should point you towards the report’s Appendix E - ‘Exposure of trackworkers to risk’ - which offers an insightful history of track safety through the ages. It’s well worth a read. I would however question whether it was worth waiting 14 months for.

Story added 1st December 2008

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

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