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Wrong place, wrong time

A quote for you from Network Rail's website: "Safety is at the forefront of everything we do".

Of the eight patrolmen responsible for the five miles of railway around Grayrigg - site of the fatal crash in February 2007 - only three held valid competence certificates. Red zone working restrictions drove their inspections into the daylight hours between dawn and 1000 on a Sunday morning, when a regular possession was booked. But this proved insufficient during winter months. To complete their duties, some teams were forced to split up and work alone, leaving these men without appropriate protection.

"Safety is at the forefront of everything we do".

In the year preceding the crash, the track team at Carnforth voiced repeated concerns about access. Available weekend possession time was slashed from 29 hours to 11. The local infrastructure manager sought a way forward from the West Coast Route Modernisation project. Although five initiatives were evaluated, the project team disbanded before any of them was approved as sustainable. By the autumn of 2006, a critical maintenance backlog had built up.

"Safety is at the forefront of everything we do".

The Track Section Manager often worked 60 hours per week but still didn’t have time to perform all of his compulsory inspections. Overtime restrictions, a vacant assistant’s post and Network Rail’s introduction of ‘Assessment in the Line’ - its new competence management system - all placed additional burdens on his shoulders. He found himself supervising weekend maintenance as so many of his men were swallowed up by the Sunday patrolling regime. Five days before the crash, with other problems on his mind, he forgot to inspect the track section through Grayrigg’s defective points - a job which someone else would normally have done.
Five days before the crash, with other problems on his mind, he forgot to inspect the track section through Grayrigg’s defective points - a job which someone else would normally have done.

Oh yes, "Safety is at the forefront of everything we do".

Amongst its own foot soldiers, Network Rail has nurtured a terrible reputation. In fact it’s hard to find anyone with a genuinely good word for the company. Whilst its leaders articulate their commitment to workforce safety with apparent sincerity, intimidating performance demands and an unwillingness to grasp trackside nettles expose its true nature. Realistic staffing levels, proper access, fixed warning systems - they could all drive our safety statistics in the right direction. But these demand both cash and effort. Instead it’s easier to glue a safety helmet onto everybody’s head.

It must be said that safety is not a duty reserved exclusively for management - we all have our role to play. In the early hours of 29th November 2007, when Tony Lundy parked his van next to an access gate and ventured onto the railway, his immediate safety was in his own hands. That he never returned to his vehicle is a tragedy which RAIB attributes largely to Tony’s actions. Whilst the Branch’s uncomfortable conclusions - published on 28th October - fairly reflect the course of events, there is something of a hole in them.

On the night in question, a T3 had been taken of the Up & Down Relief lines between Reading and Slough, due to be given up at 0545. With an hour to spare, the Engineering Supervisor called the PICOP to inform him that his work was complete and he no longer required the possession. In turn, the PICOP called his two block road men - one of whom was Tony Lundy - and instructed them to withdraw the protection.

Having passed through an access gate to the north of the railway, Tony headed east for 66 yards, retrieved three detonators from the Up Relief, removed the Possession Limit Board and placed it in the cess. The protection for the Down Relief was a further 418 yards away. At 0449, he phoned the PICOP to confirm that both lines were clear. All that remained for Tony to do was walk back to the access point - a journey which would take a little over five minutes.
Looking east from the detonator protection position on the Up Relief.

Picture Source: RAIB Rail Accident Report (Crown Copyright)

At the very moment that Tony was talking to his PICOP, empty coaching stock 5W01 left its depot to the west of Reading, destined for Slough. A red signal soon forced the driver to slow while an On Track Machine made a conflicting movement. By the time it had passed, the relief lines’ possession had been given up so the signaller took the opportunity of routeing the train via the Up Relief to confirm the correct operation of the track circuits, as the Rule Book required him to do.

It was a typical February night. Tony Lundy was fighting wind and rain as he trudged back towards his van. On top of his dark fleece, he wore a padded high-visibility waistcoast which was unzipped. His trousers were also dark. As well as a torch and PLB, he clutched an umbrella for shelter.

For his walking route, Tony had chosen the least-worst of three options. The inclined ballast shoulder proved unattractive, being slippery and uneven. Network Rail discourages feet on cable troughing due to the risk of a lid collapsing or springing up when stood upon. Signalling equipment obstructed the cess - an unhelpful hazard in the darkness. This left the four-foot.

As 5W01 passed the access gate, it had reached 45mph. Then, with just one second to take action, the driver caught sight of someone on the track. He applied the emergency brake and blasted the horn. Tony Lundy suffered a glancing blow to the head, injuring him fatally.

The inquiry found that Tony had insufficient warning of the approaching train. Two foul-weather jackets were discovered in his locker - instead of wearing one, he had used an umbrella, restricting his sighting distance to around five yards. Moreover, if he had returned to the access gate before calling the PICOP, his return trip would have been protected by the possession arrangements. This was the intended safe system as documented in the Rimini pack. As it was, all lines had reopened.

Tony was 62 and had served the railway for more than 20 years. He was everybody’s friend and never without a smile. Colleagues looked upon him as competent and reliable; they also knew that he used an umbrella. Unfortunately, the managerial support structure which might have detected this behaviour had failed.

In February 2007, Tony had been transferred to the Area Delivery Planning Manager’s department. Safety tours, briefings and inspections were rare events here - a fact which had not gone unnoticed. An action plan was being developed to address this weakness but it had not been finalised.

The team was lead by a Possession Coordinator who was obliged by a Network Rail Standard to visit block road men on site every 16 weeks, identifying any unsafe acts. But the PC had difficulty accommodating their shift patterns. His working week routinely exceeded 50 hours; he also took work home with him. Nine months before the accident, his PTS qualification had expired - he was therefore not allowed to go on the track.

Amongst RAIB’s recommendations is a ban on the use of umbrellas by staff on or near open lines. Block road men should ideally wait until they are in a permanent position of safety before informing the PICOP that protection has been removed. More generally, Network Rail is encouraged to take a critical look at T3 arrangements, with the aim of reducing trackside exposure for staff. This is something which has long been promised but, again, NR has not acted on its words.

But something’s missing. Tony Lundy would still be alive today if he had chosen to walk clear of the line, in a position of safety. RAIB’s report states that, in a red zone, walking in the four-foot is discouraged unless there is no alternative, yet it goes on to describe its use in this case as “reasonable”.
The picture above shows the West Coast Main Line at Winsford, Cheshire. If, for example, the possession had been taken here, Tony would have enjoyed the benefits of separation whilst marching from gate to detonator. Contrast this clear, level path with the cess at Reading, shown below.
Looking west along the Up Relief - the accident occurred just beyond the signal.

Picture Source: RAIB Rail Accident Report (Crown Copyright)

Yes, it might be typical of cesses across the network, but does that mean it’s acceptable? Has the industry fulfilled its obligation to provide a truly safe means of access?

Do you walk down the middle of the road when there’s a perfectly good pavement?

Story added 1st January 2009

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

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