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Golden nuggets in dark corners

I don’t read much. Is that a peculiar confession for someone who puts pen to paper? When needs must, I’ll fight my way through the toughest missive but rarely by choice. To me, the appeal of a document is inversely proportional to its thickness. In part this explains my wholesale disapproval of the Rule Book - that and its incessant use of Double Dutch!

Thankfully I’m not alone in my trait. Your average trackworker is no lover of paperwork either, which is unfortunate given that it falls from the sky faster than a Russian airliner. Much of it can be sent for recycling without a page being turned - problem is, hiding in its darkest corners, rare golden nuggets are to be found.

Take the near death experience at Manor Park on the route from Liverpool Street to Ipswich, which has just dribbled from RAIB’s investigation machine 16 months after entering the history books. Here, two words in a voluminous Rimini pack would have set alarm bells ringing if only they’d caught the eye. Instead eight men had to scramble for their lives when a train rampaged through their worksite at 80mph, shredding wheelbarrows as it went. Two of those on-track needed hospital treatment whilst the driver suffered shock and was relieved of his duties.

Contractor Kier Rail had initially booked the work - involving repairs to retaining walls at Manor Park and Seven Kings - into a 17-mile possession of the Up and Down Main Lines, from 0100 on Sunday 19th March 2006 until 0330 on the Monday morning.

Eight weeks out, a planning meeting lead to the Manor Park job being incorporated into a Network Rail owned worksite. Then, on 13th February, for reasons which have still not been established, the possession was curtailed such that the block at Manor Park would last only eight hours, not the original 26½ - insufficient time to carry out the repairs. Interested parties met again the following day, including Kier’s possession planner but he failed to appreciate the significance of this change.

Working separately, the company’s Rimini planner checked the Final WON and, on spotting the shortened times, discussed with his Contracts Manager the possibility of reallocating resources to the site at Seven Kings. Documents were prepared on this basis and the planner confirmed Kier’s intentions when he attended yet another possession meeting on 14th March.

At T-minus-two days, he left the Rimini plan on his Contract Manager’s desk who was still labouring under the misapprehension that Manor Park was a goer. It was sent to site for issue, but nobody read it.

At 0715 on the morning of Sunday 19th March - two miles from the documented site - the Manor Park COSS was handed his Rimini by the site supervisor. It totalled 17 pages, with a 32-page possession pack appended to it. A method statement must also have reared its head as the COSS gave a briefing on it. He had 45 minutes to digest the contents and convey any relevant information to his troops. He focussed on finding the phone number of the Engineering Supervisor. At no point did he register the disparity in locations - those two words ‘Seven Kings’.

Shortly after eight o’clock, he had a one minute conversation with the ES - who’d just come on-shift - describing his work and location. It ended with both parties hopelessly ignorant of the impending doom. Contrary to the rules (which were impractical for this eight mile worksite, hosting 12 workgroups), the ES made an entry on his certificate but it was not signed by the COSS.

At around 0820, the COSS, his site supervisor and seven charges walked onto the railway at Manor Park. Ten minutes later, the possession was shortened leaving the workgroup oblivious to their predicament - marooned on a high speed line, devoid of any protection. The inevitable happened at 0923. An Ipswich-bound train approached at speed. With horn blaring and emergency brake applied, it ploughed through the site. Although the group scattered, several were struck by flying debris.

Only when the COSS reported the incident to the ES did the fog suddenly lift.

Plainly, this event had the potential to be truly catastrophic yet I found RAIB’s report rather lame. The glossary contains basic errors - for example, its definition of a T2 predates the Rule Book changes of August 1999 whilst a safeguarded green zone can apparently be created by erecting a fence! More worryingly, its sources of evidence do not list those working on-track, only “key staff involved in the possession planning process”. Surely this has to be a clerical oversight.

There is a recognition that the cycle of possession meetings and complexity of allied documentation could lead to overload. At many levels, the chain of communication is called into question. But there’s a tangible sense of disappointment that every conversation anyone ever had was not minuted for RAIB’s benefit. “There are no contemporaneous records” it says of one planning meeting. When the Rimini planner spoke with his Contracts Manager, “there is no written record of this discussion.”

It all feels a bit blinkered. The implication seems to be that progress should be stifled to protect ‘the rules’, rather than the rules evolve to reflect innovation. Judgment is passed on today’s working practices - our bible’s efficacy is just taken for granted.
Judgment is passed on today's working practices - our bible's efficacy is just taken for granted.

Underlying issues relating to COSS culture were apparently out-of-scope. It’s my view that, post Rimini, many COSSs have a sense of diminished authority and see themselves as little more than implementation agents. Would this accident have occurred if our safety critical friend had planned the protection himself, assuming he still had the skill?

And then there’s that paperwork. The time available to read the Rimini plan and its format “were both contributory factors to the incident”. But there’s no condemnation of a system which places 50 pages of verbiage in a COSS’s hands and seriously expects him to read it. And the same for tomorrow’s job. And the same the day after that. They weren’t rebuilding the Great Wall of China, were they?

It’s fair to say that these eight men were almost terminated because every one of the industry’s defences failed. Meetings were held, plans were polished, notices went to press. No doubt, ticks appeared in every box. But all that investment was for nothing because its output was comprehensively unfit for purpose. And nobody noticed.

Once again, at great cost, quantity triumphed over quality. When will we ever learn?

Story added 1st September 2007
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