Search this site
Delude Retreat Indemnify Prevaricate Squander

Practice makes perfect

Accidents are unequivocally bad things but that doesn’t mean we can’t extract positives by learning lessons from them. And so we instigate inquiries to provide insight that should make the future safer. When Mark Williamson was killed by a train after poor cess conditions drove him to walk too close to the track at Hitchin, the industry immediately embarked on a huge lineside improvement programme. After Mark Falivena succumbed to an HST at Desborough that approached without a warning being given, safety professionals banned the use of site wardens. Or at least that’s what happened in the parallel universe where health and safety revolves around practical safeguards, not fine words, bureaucratic trivia and arse covering. In that context, the near miss that almost claimed two lives at Roydon in July 2012 should prompt the driving up of competence levels and full responsibility for safe systems being devolved back to the COSS. Instead committees will probably embark on months of statistical shuffling and research into font sizes. You can bank on there being repetitions.

The bridge comprises three longitudinal girders that obstruct any position of safety.
Picture Source: RAIB Rail Accident Report (Crown Copyright)

On Monday 16th July last year, a Network Rail structure gauging team had been assigned to take measurements between the platforms at Bishop Stortford Station. A brief blockage of all lines had been booked for this purpose, adding a fixed point to the team’s schedule for that day. However, before leaving base, their planner identified that they would also have time to complete three other tasks nearby which formed part of a backlog, one of them being on a bridge just to the east of Roydon Station.

Needing to generate the obligatory paperwork quickly, the planner - whose safe system of work planning qualification was probationary - produced a single SSoW pack to cover the additional sites. This specified red zone working protected by a single lookout. Although he had some knowledge of the area, the planner was not specifically familiar with the location or the bridge; neither did he check the curvature of the line or what the sighting distances were. When it was handed to the COSS 15 minutes before his departure, the pack had not been authorised for “same shift verification” by a responsible manager as the relevant Standard requires. The COSS queried the use of just one form to cover three separate sites but was told this was fine. Without signing to accept the pack or checking its contents, he accepted the assurance and left.
Without signing to accept the pack or checking its contents, he accepted the assurance and left.

The COSS had been acting in the role for a year or so, but this had mostly involved overnight activity in green zones. The lookout had only completed his training one month earlier whilst the group’s third member was an occasional trackworker. Collectively, they didn’t muster a wealth of experience. The COSS dutifully briefed his subordinates, positioned the lookout and walked onto the bridge with his colleague. A Cambridge to Liverpool Street train then approached on the same line as them at 62mph.

The bridge carries a two-track railway for a distance of 21 yards and comprises three longitudinal girders - one at either side of the railway and another in the six-foot. Clearances are therefore limited, with the structure offering no position of safety. As the lookout spotted the train and shouted a warning, the group attracted the driver’s attention 330 yards ahead. He sounded a long blast on his horn and applied the brake a little. With the train fast approaching, the two men started to run towards their position of safety beyond the far end of the bridge, prompting the driver to hit the emergency brake. Two seconds after reaching sanctuary in the cess, the front of the train passed them. To his great credit, the COSS recognised that an error had been made and reported the incident.

Sighting distances at the site were restricted considerably by a curve. This meant that the lookout could only see about 380 yards. From the middle of the bridge, it took around 10 seconds to respond to any warning and walk off the structure to the position of safety. However, at 62mph, the train would cover 380 yards in 13 seconds, or just 11 seconds at the 70mph linespeed. The COSS had been led to believe that overhead line stanchions were positioned at intervals of no less than 100 yards. On that basis, he had calculated the sighting distance to be 700 yards - exactly what he needed to provide 20 seconds warning. He was of course wrong in his belief, an error that nearly brought tragedy with it.

The site lookout's view of trains approaching around the curve on the Up line.
Picture Source: RAIB Rail Accident Report (Crown Copyright)

Through failure and cock-up, the system of work proved deficient in several regards. RAIB characteristically audited everyone’s actions against the stated requirements and found a number of non-compliances. But yet again the Branch has been unwilling to dig deeper in search of the fundamental causes, so I won’t distract you by regurgitating its conclusions.

The seeds for this incident were sown years before with Rimini’s implementation. This removed responsibility for planning safe systems of work from the COSS, giving it instead to office-based staff, many of whom had high workloads and little on-track experience. As a result, it was approached largely in a binary manner, the choice of safe system being unduly influenced by the emphasis placed on green zone working as the preferred method of protection and a deep-seated misunderstanding over the application of green/red zone rules when lines are blocked. Inappropriate safe systems were sometimes specified purely to make green zone usage statistics look better.

Allied to this, the COSS’s ultimate authority for on-site safety was blurred by an instruction that required managerial permission to be sought for any degradation of the plan. Over time, this has induced a mindset shift whereby many COSSs now see their role as being merely to implement whatever is stipulated in the pack, come what may. Not many have the courage to ring the office and challenge approved paperwork, even if they have doubts about it. Exacerbating this situation, through lack of practice, is a weakening of their proficiency in developing safe systems for themselves. You can’t successfully evaluate a plan if you’re no longer able to formulate one yourself. It’s all very well being assessed as competent in an online test; it’s different altogether when you’re working under time constraints in the field and your mates’ lives depend on you getting it right.

The COSS at Roydon was let down by systemic failure: circumstances contrived to put him in a perilous situation which he didn’t have the skills to recognise and disarm. The fundamental principles behind Rimini remain absolutely sound: plan the job, resource the plan, deliver the safest protection. But the devil is in the detail. Rimini and its successors loosened the COSS’s ‘ownership’ of their safe system, left them lacking appropriate planning disciplines and robbed of vital knowledge. Those are wrongs that need righting before the next breakdown has more lasting consequences.

As he recovers from his experience, we ought to spare a thought for the S&T worker who was struck a glancing blow by a train near Poole Station on 12th July. An employee of MGB Engineering, the man had been working in a lineside cabinet about 415 yards London side of the station, but needed some extra equipment. He was walking alone back to the access gate - alongside the Up line - when he was hit from behind by a step on the leading coach of a Bournemouth to Poole train. This had approached on the Down line but crossed over shortly after passing the cabinet. Fortunately only minor injuries were sustained.

RAIB’s investigation is looking into the planning of the safe system and whether all members of the group were aware that bidirectional working was permitted over a short section of the Up line where the accident occurred.

On this occasion, the inquiry’s conclusions should be worth reading. On its face, the event has “one of those things” written all over it, but RAIB’s aversion to people being near points on open lines will probably provoke more disproportionate proposals. Sooner or later, the Safety Taliban will succeed in shutting the railway down altogether for even the most benign of activities.

Story added 1st September 2013

Page Top

Front Page | Safety Valve | Jungle Ron | Newshound | Red Tape | On The Line
Four by Three | Forgotten Relics of an Enterprising Age | God's Own County | Image Library

© Four by Three 2014