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On the blind side

Once upon a time - before our leaders appended their names to the Lisbon Treaty and a barrel of oil burst through the $100 barrier - a trackworker had a near death experience on the approaches to Victoria Station. Whilst those immediately involved continue to live with its consequences, the accident has long since been wiped from the railway’s collective consciousness.

RAIB’s inquiry team immediately swung into action, sifting through the evidence for the root causes. In a matter of days, its conclusions had been reached and a report almost finalised. Regrettably, a little-known virus - Latin name shambolico totalius - then established itself in the Branch’s Woking headquarters, causing all its inspectors to enter a deep vegetative state. Shortly before his death, Jeremy Beadle broke into the building and concealed 19 witness statements down the back of a settee. A safe containing voice tapes was eaten by a crocodile. And to cap it all, a devastating pulse of electromagnetic radiation was erroneously discharged from a laboratory near Bagshot, erasing every piece of digitally-stored data across north-west Surrey.

It was against this incredible backdrop that RAIB’s report into that unfortunate event near Victoria was eventually published, 611 days after the event. “Better late than never”, as someone with time on their hands once said. The Branch must be congratulated for completing its duties in such challenging circumstances, only eight months outside the regulatory 12-month limit. It’s an extraordinary achievement, one which will soon be immortalised in a pantomime at Billy Smart’s Circus.

Looking towards Victoria from the six-foot between the Up and Down Chatham Fast lines.

Picture Source: RAIB Rail Accident Report (Crown Copyright)

Let’s go back then to the autumn of 2007; 13th November in fact. A 47-year-old leading trackman - whose 11 years railway experience included two as a patrolman at Victoria - was tasked with carrying out a visual inspection of the Chatham and Stewarts Lane lines between 0m 40ch and 1m 16ch - a routine activity which took place every Tuesday. Accompanying him was a lookout and a trainee who was being mentored. The patrolman shouldered the additional burden of COSS duties.

Patrol 4A involved walking towards traffic in the four-foot of the Up Chatham Slow, checking for any defects on this and the neighbouring line, the Down Chatham Slow. At Battersea Pier Junction, the patrolman turned his attention to the Up Stewarts Lane line as far as Battersea Park Road bridge before returning via the Down Stewarts Lane and Down Chatham Fast lines, observing the Up Chatham Fast as he went.

As they approach the Victoria terminus, the Chathams - on the eastern side of the formation - come together with the Brighton lines to create a nine-track railway across the Thames. Alongside them, a disused trackbed forms a handy cess. On reaching the river’s northern bank, the railway immediately crosses Grosvenor Road on a separate structure. Here, the spaces between the tracks are occupied by pairs of 1.1m-high parapets.

Crossing the Thames, looking north towards Grosvenor Road bridge which is just beyond the signal displaying a double yellow aspect.

Picture Source: RAIB Rail Accident Report (Crown Copyright)

At 1400, the driver of 2A32 saw three men walking in the four-foot of the Down Chatham Fast line as his train, on the Up Chatham Fast, drew towards the southern end of the Thames bridge. He briefly sounded the horn, prompting an acknowledgment from both the trainee and the lookout.

Close to Grosvenor Road bridge, the patrolman stepped into the six-foot, towards the line on which the train was approaching. “I nearly walked in front of that” he was heard to exclaim, referring to 2A32. He returned to the sanctuary of the Down line and the trio walked in single file across the bridge. In the distance, they spotted another patrol gang heading back to the depot having apparently finished their inspection early. This provoked some predictable banter.

Beyond the bridge, with his spanner over his shoulder, the patrolman once again ventured into the six-foot. Seconds later, there was a bang. The trainee and lookout - a short distance ahead - turned around. Their colleague was lying on his back with one boot touching a conductor rail; they pulled him clear.

The train, which had been travelling at 27mph, was brought to a stop by an emergency brake application. Its driver contacted the Victoria Area Signalling Centre where the signaller blocked the relevant lines and arranged an isolation. This had the knock-on effect of stranding several trains between stations without power for auxiliary systems. Such difficulties did though pale into insignificance when compared with the serious injuries sustained by the patrolman - these included multiple fractures and brain damage.

The safe system implemented on that day had been planned by a Works Scheduler at Croydon, where the local maintenance delivery unit was based. The department was historically short-staffed - indeed the person responsible for the Victoria track section had been off sick for some considerable time. Their workload was absorbed by others, unfamiliar with the area, resulting in an almost-overwhelming volume of work. Perhaps as a result, the supplied COSS form contained several errors and inconsistencies, including the wrong method of protection being specified.

The raised parapets on Grosvenor Road bridge obscured the adjacent track, making a proper inspection of the Up line impossible from the four-foot of the Down. This effectively drove the patrolman to act in a manner which had neither been identified nor mitigated in the planning or execution of the safe system. The presence of the trainee affected the dynamics of the group, resulting in the lookout not being as attuned to the patrolman’s actions as he might otherwise have been.

None of which explains why the patrolman twice moved towards a line on which a train was approaching, rather than acknowledge the driver’s warning and then stand clear until it had passed. The explanation is, of course, embedded in the culture of those who work in such heavily-trafficked areas. Here, meticulous compliance with ‘the rules’ would impact significantly on the time taken to complete a job; instead, a perpetual stream of judgement calls are made by those involved. When it works, it can be remarkable to witness; when it fails…

A driver's eye view of the Up Chatham Fast as their train approaches Grosvenor Road bridge.

Picture Source: RAIB Rail Accident Report (Crown Copyright)

RAIB looks for answers where none are to be found, asserting that the absence of a full COSS briefing and the lookout’s failure to challenge this “lapse” could have been contributory factors. I don’t accept this for one moment. All three members of that group knew exactly how the safe system would function before they had even left their mess room. Would the accident have happened if the COSS had stood his troops in a row and told them things they already knew? Tragically, of course it would. Indeed, given the failings with the paperwork, a comprehensive briefing would probably have confused matters.

It’s a managerially inconvenient truth that informality becomes the norm when the same group of people are tasked with the same duties day-in day-out. Don’t confuse ‘informality’ with ‘unsafe’ - the two are not mutually exclusive - it’s just alien to our safety professionals with their structured, procedural approach. I can’t advocate informality but I firmly believe that it must be recognised and accepted if safety is the end game. It can’t be eradicated because it has a life of its own - it must therefore be managed.

To me, the safe system was lacking in one critical regard - no allowance was made for human error. The requirements of the inspection coaxed the patrolman into the six-foot yet the lookout had been instructed to warn only of trains using the line on which they were walking - the Down Chatham Fast. In practical terms, this might have been unnecessary as the line was blocked by a T2A closer to Victoria. Unfortunately, the report does not tell us the effective limits of this protection or whether any trains were actually signalled along that line. Either way, if the default had been to warn of trains on the adjacent line as well, it’s fair to presume that the accident would have been averted. Unsurprisingly, this is not a conclusion reached by RAIB.

...if the default had been to warn of trains on the adjacent line as well, it’s fair to presume that the accident would have been averted.

Instead it immerses itself in minutiae, returning to one of its favoured sideshows - the absence of a Rule Book definition for the term ‘approaching train’. No documentary evidence could be provided to prove that the men had been mentored - a fact which is bemoaned. It even asks whether the casualty’s injuries might have been less severe had he been wearing a hardhat!

One recurrent theme does emerge from the report’s pages - the heavy workload shouldered by supervisory staff. The local ‘boots on ballast’ initiative obliged the Track Section Manager to regularly monitor the behaviour of his staff through on-site visits, but administrative duties often got in the way. The same applied to his two assistants. So Network Rail has now introduced a new company Standard, adding more bureaucracy in the form of a ‘Manager’s Notebook’! They really have no idea, do they?

Two other issues are worthy of note. It has become apparent that Network Rail only facilitates green zone working for routine patrols in busy areas if a red zone system cannot be safely implemented. In other words, red zone is first choice and green zone second - the absolute reverse of what Rimini demands. NR takes this approach because, in its view, widespread green zone working would have an unacceptable impact on the number of available train paths. A project to ‘redesign’ the Rimini process - including the roles, responsibilities, information systems and paperwork which supports it - was due to be completed in June. Standby for Rimini to get lost in the long grass.

The actions of the driver also come in for detailed scrutiny. He gave an initial short blast on the horn 26 seconds before the accident, resulting in an acknowledgement from only two members of the group. There was no repeat of the warning when the patrolman first strayed towards to the Up Chatham Fast - an act which the driver apparently did not see - or when he moved back into the six-foot at the far side of Grosvenor Road bridge.

The report claims that the driver was aware of the danger to the COSS because, four seconds before the accident, he momentarily applied the brake. But no evidence is provided to substantiate this link. Surely, on the approach to a busy terminus station, there are any number of factors which might cause a driver to slow his train. In any case, one of the fundamentals of any safe system is that it cannot rely on a warning from a driver - it must be assembled only from building blocks directly under the COSS’s control.

RAIB could find nothing to support the driver’s assertion that excessive horn blowing is discouraged because of its impact on the wider community. All I can say is that the Branch clearly didn’t look very hard. Between 2004-7, when the industry was addressing concerns about the effect of horns on railway neighbours, central to its approach was minimising their use. Indeed, at one point, RSSB asserted that “The general thinking is that virtually all routine uses (apart from whistle boards) could potentially be removed”. An overnight quiet period resulted, with limitations imposed at other times. Hardly surprising then that some drivers are reluctant to sound them.

A train approaches Grosvenor Road bridge on the Up Chatham Fast.

Picture © GoogleEarth/Bluesky 2009

Placing a responsibility on individuals to ensure that they receive a COSS briefing is the first of nine recommendations. This one falls into the ‘unrealistic’ category as it fails to take account of the often feudal relationship between the workgroup and COSS who, in many cases, is also their supervisor or the ‘person in charge’. RAIB adds that Network Rail should review its programme for the provision of automatic warning systems for red zone track inspections. This came as something of a shock as I didn’t know it had one!

If their intent is to prevent a similar accident, the other recommendations are hardly worth mentioning - with one exception. The Branch requires Network Rail to provide clear and unambiguous instructions/guidance on how to establish a safe system in multi-track areas where trains could approach on lines unaffected by the work. This has to be supported but, given its track record, it is questionable whether NR has the skills to do this in a coherent and worthwhile manner. Its communication of straight-forward concepts is often rather woolly; with an issue as complex as this, expect a flock of sheep.

This is an inquiry report with much light and shade. Some of it illuminates; other parts take lengthy diversions down blind alleys. Generally, it reinforces my view that RAIB’s inspectors do not like to leave the sterile bubble of paperwork and theoretical instructions - some of which are silent on significant issues - and enter the muddy hinterland where human factors lurk.

As far as the safe system is concerned, one small adjustment would have made a big difference but that fails to make its presence felt in the report’s 56 pages. The fact that it took more than 20 months to complete is beyond a joke; the lesson learning process should have got underway - with the benefit of RAIB’s insight - within weeks of this event. As it was, the nation witnessed financial meltdown and Olympic glory between occurrence and publication. How can that possibly be justified?

Story added 1st September 2009

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

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