An investigation into the death of two rail track workers hit by a train has found that Network Rail failed to address relevant safety concerns highlighted in 44 previous investigations over 14 years.
The two rail track workers lost their lives because there were no formally appointed lookouts to warn them of the oncoming train and the likely use of ear defenders meant they could not hear it, the Rail Accident Investigation Branch (RAIB) concluded. Another worker came close to being hit.
The RAIB has released a report into the deaths of Gareth Delbridge and Michael Lewis who were killed at Margam, in Wales, on 3 July 2019.
It makes a series of criticisms of Network Rail and says that 'over a period of many years, Network Rail had not adequately addressed the protection of track workers from moving trains'.
Underlying factors
Network Rail contributed to four underlying factors that created the situation around the deaths:
- The major changes required to fully implement significant changes to the standard governing track worker safety were not effectively implemented across Network Rail’s maintenance organisation.
- Network Rail had focused on technological solutions and new planning processes, but had not adequately taken account of the variety of human and organisational factors that can affect working practices on site.
- Network Rail’s safety management assurance system was not effective in identifying the full extent of procedural non-compliance and unsafe working practices, and did not trigger the management actions needed to address them.
- Although Network Rail had identified the need to take further actions to address track worker safety, these had not led to substantive change prior to the accident at Margam.
The railway at Margam
Simon French, chief inspector of rail accidents said: 'This accident has reinforced the need to find better ways to enable the safe maintenance of the railway infrastructure. The areas that need to be addressed to improve the safety of track workers have been repeatedly highlighted by 44 investigations carried out by RAIB over the last 14 years.
'The most obvious need is for smart and accurate planning to reduce the frequency with which trains and workers come into close proximity, while also meeting the need for access to assets on an increasingly busy railway system.
'I believe it is essential that Network Rail addresses the fundamental requirements that have been highlighted by RAIB’s investigations over the years.'
He said these included:
- developing leadership skills and involvement of the site team in the planning process, including the identification of site hazards and the local management of risk
- better management of people who work on the track
- greater use of technology to control access to the infrastructure, to provide warnings of approaching trains or to protect possession limits.
Immediate factors
Several factors led to the fatal incident on the day, including the way the safe system of work was planned and authorised, the way in which the plan was implemented on site, and the lack of effective challenge by colleagues on site when the safety of the system of work deteriorated.
The RAIB said: 'The accident occurred because the three track workers were working on a line that was open to traffic, without the presence of formally appointed lookouts to warn them of approaching trains.
'They were carrying out a maintenance activity which they did not know to be unnecessary. All three workers were almost certainly wearing ear defenders, because one of them was using a noisy power tool, and all had become focused on the task they were undertaking.
'None of them was aware that the train was approaching until it was too late for them to move to a position of safety. Subsequent acoustic measurements have shown that they would not have been able to hear the train’s warning horn.'
According to the RAIB investigation the system of work that the controller of site safety had proposed was not adopted and the alternative arrangements became progressively less safe as the work proceeded.
That created conditions that made an accident much more likely.
RAIB recommendations
The report made eleven recommendations. Nine of these are addressed to Network Rail and cover:
- improving its safe work planning processes and the monitoring and supervision of maintenance staff (three recommendations)
- renewing the focus on developing the safety behaviours of all its front-line track maintenance staff, their supervisors and managers
- establishing an independent expert group to provide continuity of vision, guidance and challenge to its initiatives to improve track worker safety
- improving the safety reporting culture
- improving the assurance processes, the quality of information available to senior management, and processes for assessing the impact of changes to working practices of frontline staff.
A further recommendation was made jointly to Network Rail, in consultation with the Department for Transport, relevant transport authorities, the Office of Rail and Road (ORR) and other railway stakeholders, to investigate ways to optimise the balance between the need to operate train services and enabling safe track access for routine maintenance tasks.
The final recommendation addressed to the Rail Delivery Group, in consultation with Network Rail and RSSB, urges research into the practicability of enabling train horns to automatically sound when a driver initiates an emergency brake application.
RAIB has also noted two learning points: one reminds staff to only carry out maintenance on insulated rail joints when the relevant line has been closed to traffic, and the other reminds companies to update staff on revised maintenance practices as railway assets are modernised.
Martin Frobisher, Network Rail’s safety director, said: 'We owe it to Gareth and Spike to do everything in our power to prevent another tragedy on our railway.
'That is why we welcome these recommendations by the Rail Accident Investigation Branch (RAIB), building on our own report earlier this year and further improving our understanding of what went wrong. We have already taken action to improve safety for rail workers, making changes to how work is planned and carried out – for example by significantly reducing the practice of lookout working – and improving safety leadership and culture within the organisation.'
Summary of events
At around 09:52 hrs on Wednesday 3 July 2019, two track workers were struck and fatally injured by a passenger train at Margam East Junction on the South Wales main line.
A third track worker came very close to being struck.
The three workers, who were part of a group of six staff, were carrying out a maintenance task on a set of points.
The driver made an emergency brake application about nine seconds before the accident and continued to sound the train’s horn as it approached the three track workers. The train was travelling at about 50 mph (80 km/h) when it struck the track workers.
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