August 20, 2018 | Susan Napier-Sewell

Monday Accidents & Lessons Learned: One Second Away from Major Tragedy

Have you ever felt that you couldn’t challenge a company practice for fear of losing face or your position? It happens more often than you may imagine. Concerning recent findings from a 2017 Nottinghamshire incident investigation by the Rail Accident Investigation Branch (RAIB), Chief Inspector of Rail Accidents Simon French commented, “When the person in charge of a team is both a strong personality and an employee of the client, it can be particularly hard for contract workers to challenge unsafe behavior.” Inspector French further observed, “We have seen this sort of unsafe behavior before, where the wish to get the work done quickly overrides common sense and self-preservation. When we see narrowly avoided tragedies of this type, it is almost always the result of the adoption of an unsafe method of work and the absence of a challenge from others in the group.”

The incident
Around 11:22 am on October 5, 2017, a group of track workers narrowly avoided being struck by a train close to Egmanton level crossing, between Newark North Gate and Retford on the East Coast Main Line. A high-speed passenger train was approaching the level crossing on the Down Main line at the maximum permitted line speed of 125 mph (201 km/h) when the driver saw a group of track workers in the distance. He sounded the train’s warning horn but saw no response from the group. A few seconds later, the driver gave a series of short blasts on the train horn as it approached and passed the track workers.

The track workers became aware of the train about three seconds before it reached them. One of the group shouted a warning to three others who were between the running rails of the Down Main line. These three workers cleared the track about one second before the train passed them. During this time, thinking his train might strike one or more of them, the driver continued to sound the horn and made an emergency brake application before the train passed the point where the group had been working. The train subsequently came to a stop around 0.75 miles (1.2 km) after passing the site of work.

The immediate cause of the near-miss was that the track workers did not move to a position of safety as the train approached. The group had been working under an unsafe and unofficial system of work, set up by the Person in Charge (PiC). Instead of adhering to the correct method of using the Train Operated Warning System (TOWS) by moving his team to, and remaining in, a position of safety while TOWS was warning of an approaching train, the PiC used the audible warning as a cue for the lookout to start watching for approaching trains in order to maximize the working time of the group on the track. This unsafe system of work broke down when both the lookout and the PiC became distracted and forgot about the TOWS warning them of the approaching train.

Although the PiC was qualified, experienced, and deemed competent by his employer, neither his training nor reassessments had instilled in him an adequate regard for safety along with the importance of following the rules and procedures. Additionally, none of the team involved challenged the unsafe system of work that was in place at the time. Even though some were uncomfortable with it, they feared they might lose the work as contractors if they challenged the PiC.

As a result of its investigation the RAIB has made three recommendations. These relate to:

    1. Strengthening safety leadership behaviour on site and reducing the occurrences of potentially dangerous rule breaking by those responsible for setting up and maintaining safe systems of work;
    2. Mitigating the potentially adverse effect that client-contractor relationships can have on the integrity of the Worksafe procedure such that contractors’ staff feel unable to challenge unsafe systems of work for fear of losing work;
    3. Clarifying to staff how the Train Operated Warning System (TOWS) should be used.

Lessons learned
The findings of this investigation also reinforced the importance of railway staff understanding their safety briefings and challenging any system of work that they believe to be unsafe.

Inspector French added this comment to the findings, “We are therefore recommending that Network Rail looks again at how it monitors and manages the safety leadership exercised by its staff, and how they interact with contractors. There have been too many near-misses in recent years.”

Circumstances can crop up anywhere at any time if proper and safe sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

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