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.

Privatisation… nationalisation… or regionalisation?

Bold reform. That’s the call from Paul Plummer at the top of the Rail Delivery Group for the review by Keith Williams, the former chief executive of British Airways.
Yet Transport Secretary Chris Grayling has already clipped his wings by pledging that Network Rail will remain nationalised. He told the Transport Select Committee last July: “I do not envisage us seeking to sell off the infrastructure. I do not see Network Rail ceasing to be the owner of the infrastructure and the state being the owner of the infrastructure.”
Or has he? For he also said: “The devolution of Network Rail from a centralised organisation to an organisation of devolved route-based businesses is the essential next step to paving the way for them to create the kind of partnerships the railway needs for the future.
While it would be truly bold to sell Network Rail back to the private sector in which infrastructure sat for most of the railway’s first century, such as sale is unlikely to find much support from inside or outside the rail industry. At privatisation in the early 1990s, ministers hoped that by selling track, signalling and structures there would be no need for government to spend money on them. The private sector would invest and receive a return over a long period, matching the life of steel and concrete is was paying for. History shows that this hope quickly perished with past years of government underfunding demanding more money than anyone expected.
Grayling wants closer links between track and train. He wants NR to devolve. This points towards regional rail companies running both. Just as government franchises rail services to private companies so it could lease tracks to private companies. They could be grouped regionally to give a railway like that envisaged by John Major when, as prime minister, he privatised rail. Alternatively, they could be grouped by user which would replicate the structure of British Rail’s final days. This saw, for example, InterCity responsible for main lines into London on which it was the main long-distance user.
With Grayling talking about an East Coast Partnership based on LNER’s operation from King’s Cross, this could see the partnership running LNER’s trains while operating and maintaining the East Coast Main Line. Train operators already have experience of operating and maintaining assets owned by and leased from a third party because they do this with rolling stock. Some stock leases include responsibility for heavy overhauls, others just cover maintenance. I suspect train operators will shy away from track renewals, leaving this for NR as the owner, but some will welcome the chance to become more involved with operations and maintenance because these areas directly affect the punctuality of their trains.
Of course, just as InterCity was not the sole user of the ECML’s tracks in BR days, so today the partnership operator will be required to share them with other operators. Some may be franchises – Thameslink for the southern end of the East Coast, for example – while others might be open access operators such as Grand Central or Hull Trains. Any change to leased tracks would need to put these other operators at no disadvantage but that’s the same today under current arrangements.
CrossCountry might never become a integrated track-train partnership. It might always use tracks leased to other operators and will need careful protection if its passengers are not to lose.
In particular, there would need to be close attention paid to freight operators and their needs as well as the needs of tracks used only by their trains. In BR days, its freight arm held responsibility for freight-only lines but I can’t see a freight operator taking this on today. It may be left with NR.
A future LNER might just operate and maintain the ECML leaving most of the rest of today’s NR London North Eastern Route to other operators. There’s sense, for example, in the northern part of it being packaged into the Northern franchise as a vertically integrated track and train operator running local services. TransPennine might lease the Huddersfield route across the Pennines on which it is principal operator. This could remove NR’s route boundary at Standege Tunnel to give TPE closer control of the whole line through Manchester Victoria to Liverpool.
The line is slated to see a major upgrade. Precisely what this will do isn’t known but there’s the prospect of faster journeys and more capacity. Government is committing £3 billion and is well-placed to decide how much of this investment it should recoup from passengers through the tickets the operator sells and how much should fall to wider benefits across taxpayers. With a vertically integrated operator covering track and trains, there’s more chance of agreeing an upgrade that balances the extra maintenance an upgraded railway might need with the services needed to pay for the upgrade.
If it’s to consider leasing tracks to integrated operators, government should also consider longer deals. Chiltern Railways has exemplified this approach with a series of track upgrades delivered over the life of the deal it won in 2002. The East Coast Main Line has several upgrade projects looming, such as Werrington dive-under, King’s Cross remodelling and installation of ETCS cab signalling, and there’s work to do to deliver improved power supplies north of Newcastle. Granting a longer deal gives a better chance for a track-train LNER to tie daily work into these longer upgrades. It might provide a basis for creating a partnership that includes responsibility for delivering these upgrades, perhaps by contracting NR’s Infrastructure Projects division to deliver some or all of them.
However the government chooses to reorganise England’s railways, it will need to look closely at the interfaces and boundaries between organisations. Leasing tracks to operator, whether by geography or line, cannot lead to stretches becoming orphaned with nobody responsible for them. Reorganisation cannot lead to track-train operators discriminating against companies that merely run trains. There will remain a need for system co-ordination to timetable over boundaries and a need for strategic oversight to deliver capacity over the longer-term.
But giving train operators responsibility for operating and maintaining tracks under lease deals will put the customer much closer to decisions that today are taken by Network Rail one step removed from those they most affect.

This articles first appeared in RAIL 863, published on October 10 2018.