Near misses emphasise need to focus on safety

Egmanton is a level crossing on the East Coast Main Line between Newark and Retford. I suspect few passengers could find it but some may have noticed the windmill tower by the house next to it.
Last October, it came close to entering railway history books as a 125mph express bore down on a group of trackworkers.
The train driver closed his eyes as his emergency brake slowed the train to a halt nearly a mile further north. He then had to clamber from his cab to check his train, fully expecting his worst nightmare to be realised. There was nothing to see. The final three trackworkers to clear the line had done so with a second to spare.
I can’t imagine what was going through the driver’s mind but he was cool enough to trigger an priority radio call to report the incident as his train slowed. Nor can I imagine was what was going through the minds of each of the gang as they scrambled clear, doubtless with racing hearts, as the red and white carriages flashed by.
What caused this near-miss? Broken rules and a culture that put work before safety and discouraged questions. The Rail Accident Investigation Branch published its report in early August. It concentrates heavily on the actions of one individual but doesn’t spare Network Rail and its relationship with contractors.
The individual was the team leader, the person in charge (PIC) of work, employed by Network Rail. His gang came from a labour agency, Vital Human Resources, and they were employed on zero-hour contracts.
RAIB reports use dry language as befits their dispassionate analysis. Stripped of excess language, this dryness distils and strengthens their words. “The PIC’s behaviour indicates an inadequate regard for safety. Getting the work done was prioritised to such a degree that the rules were broken and safety was compromised,” says the report.
The PIC did not brief the lookout and the group on the safety arrangements at each site they were working on. The PIC did not brief the gang on the risks surrounding their work and did not check they had the right protective equipment. The PIC did not check the gang’s safety qualifications. The PIC did not test the safe system of work before starting work. The PIC did not appoint touch lookouts before noisy work started.
The PIC and gang should not even have been at Egmanton level crossing. The PIC had been told to attend two sites and had a ‘Safe Work Pack’ (SWP) for two sites, both south of the level crossing. The near-miss was just north of the crossing at a third site.
As if this were not bad enough, RAIB then delivers a devastating message: “The actions of the PIC following the incident indicate a deliberate attempt to cover up the near miss following the phone call from the track section manager. This further illustrates the attitude of the PIC towards safety, including a belief that the Vital team would not report the incident. Had the train driver not reported the near miss, it is likely that the incident would never have been investigated.”
The track section manager was the PIC’s manager and set the work the PIC was to deliver. NR control alerted the manager to the incident following the driver’s priority call. He phoned the PIC and, according to RAIB, “asked him whether his team was involved in the report of fatalities at the level crossing. The PIC told the TSM that he was not at Egmanton, but at Tuxford. Witness evidence from a member of staff at Carlton signal box, from where Egmanton level crossing is controlled, indicates that images from the CCTV at the level crossing showed that the group left the crossing at 1128.” The incident took place at 1122.
RAIB continues: “The PIC then drove from Egmanton to an access point near Tuxford, and saw that train 1D09 had stopped at a signal. He realised that the driver would have reported the near miss. At 1138 hrs, he phoned the TSM and told him that the group had been involved in the incident.”
What then of the gang? Why had they said nothing when asked to work without safe protection from passing trains?
Put bluntly, they were scared of losing work and pay. They were on zero-hour contracts with no guarantees of work, even though some of them had considerable rail experience (enough to mitigate for some of the PIC’s failings).
Says RAIB: “Following the incident, individuals stated to the RAIB that they realised that the system under which they had been working had been non-compliant and unsafe. Some of those who were more experienced had realised this before the incident and had been providing missing safety information to others. The less experienced members told the RAIB that they trusted the others, thinking that they would not be on track if they felt it was unsafe. They also told the RAIB that initially they had an expectation that the PIC, being a Network Rail employee, would keep them safe.”
One of the gang told RAIB that he looked up every five seconds or so to check for trains as he tamped track while wearing ear defenders and said he kept an eye of Egmanton level crossing’s barriers. Of the Vital team leader, RAIB concluded amid varying witness accounts that he did not want to raise problems because he could lose work. Even the PIC told RAIB that he thought the team didn’t challenge him because they feared losing work.
“Members of the Vital team reported to the RAIB that the PIC’s attitude and manner did not make the group feel like they could question him without any repercussions. One member of the group told the RAIB that he felt that if they did not do the work the way the PIC wanted it done, they would be ‘off the job’. The PIC also regularly referred to how his own team would do tasks, implying to them that they as contractors could be replaced by his, or other contracted staff,” said RAIB.
It makes three recommendations. The first is that NR should review its processes for monitoring staff in safety roles so that only those who show the right behaviours work in these roles. The second is that NR should review its processes when its staff lead teams of contractors. The third recommendation is that NR clarify its instructions for using train operated warning systems.
RAIB includes one ‘learning point’ which is the way it draws attention to the importance of complying with existing safety arrangements: “All railway staff, including contractors and those employed through agencies, should remember the importance of understanding their safety briefings, and challenging any system of work which they believe to be unsafe, including use of the Worksafe procedure.”
Meanwhile, a day after publishing its Egmanton report, RAIB revealed a near-miss near Dundee on July 10 when a 72mph approach a gang working on a bridge. “Two workers who were working on the bridge at the time were forced to move clear of the train with very little space available between the train and parapet. The train also struck a portable generator which had been left on the line,” RAIB said.
The next week saw another RAIB near-miss notification, this time Peterborough on July 20. “The train was approaching along the up fast line at around 102 mph when the driver saw the site lookout, sounded the train’s warning horn, and applied the train’s brakes. The site lookout moved out of the path of the approaching train about three seconds before the train passed him.”
That same month, NR devoted the back cover of its in-house magazine, Network, to exhorting staff to ‘hold the handrail’ when on stairs. I realise that such small things can help build a safety culture. I realise that falling on stairs can be serious. Yet I suspect that I’m not alone in thinking there’s a gulf in risk between slipping on stairs and a train hitting a track gang at 125mph.

This articles first appeared in RAIL 860, published on August 29 2018.