RAIB report highlights lack of leadership at NR

No reports from the Rail Accident Investigation Branch make easy reading. When RAIB’s chief inspector describes an incident as alarming, the railway should sit up and pay attention.
Thankfully, there was no accident at Cardiff on December 29 2016 after Network Rail left a set of redundant points unsecured, unsupervised and in the wrong position. A train driver noticed them and stopped in time.
Something similar happened last August when NR left a set of points at Waterloo disconnected from signalling. A train ran over them, derailed and collided with stationary wagons.
Both echo back to Clapham Junction’s fatal accident in 1988 when signalling was not properly disconnected. That accident led to widespread changes in the way work was planned and supervised. Cardiff and Waterloo suggests that the corporate memory of Clapham has faded.
Work last Christmas was part of NR’s Cardiff Area Signalling Renewal (CASR) project. It started in 2006 and was completed this year after several phases. NR was the principal contractor with Balfour Beatty designing and delivering track changes and Atkins doing the same with signalling.
RAIB found that CASR’s senior construction manager (SCM) failed to identify which points needed securing and that no-one in the project was made responsible to checking they had been secured.
Don’t be tempted to point a finger at the SCM because RAIB reveals that there was no single project document that listed the points to be secured. This breached NR’s company standards.
There was a list of seven points ends that needed securing on one slide of a 123-slide Powerpoint presentation which was taken from the project’s commissioning management plan. Unfortunately this plan was wrong in listing seven points because there were eight that should have been locked and secured.
The deputy project engineer (DPE) did have a correct list of the eight points, which he’d created for his own purposes but shared with others. The SCM didn’t consult this list but, as RAIB comments, he should have been able to find the correct information he needed from the scheme plan or from the testing and commissioning plan.
The litany doesn’t end there. RAIB found the SCM was on his first 12-hour nightshift having just completed seven day shifts since his last rest day. This is a classic recipe for fatigue.
The tester-in-charge (TIC) was responsible for ensuring all changes in the design are completed. RAIB notes that this implies he should check that redundant equipment that is to be removed later to make sure it’s safe.
He used the signalling scheme plan to produce his testing and commissioning plan for Christmas’s ‘stage 5’ works. The signalling scheme plan showed stage five’s final layout as it would be following Easter 2017’s work to remove redundant points. It is possible, notes RAIB, that this led the TIC not to realise that he needed to check points made redundant at Christmas but left in place. The TIC was on his fifth of ten consecutive 12-hour nightshifts when the incident occurred.
To add to the pressure, the team found a damaged cable hours before the railway was due to reopen. This diverted the project engineer, DPE, SCM and TIC into working out how and whether parts of the railway could open on time. This was just at the time that they should have been concentrating on checking that work had been done properly. But it’s understandable that they would have wanted to have trains running on time giving the criticism NR receives for over-running engineering work.
As a result, NR’s operational management team decided to cancel route proving trains designed to check just such things as points lying incorrectly. Because the points were redundant they were no longer connected to signalling systems and didn’t appear on signaller’s screens. They were invisible such that the signaller called by the driver was initially confused although he then remembered where the old points were.
The SCM and a colleague walked the track before it opened to trains but they were concentrating on looking for tools or equipment left on the track.
So far, so bad. RAIB also delves into the reasons why this series of mistakes might have occurred. Most of the project team had worked together and trusted each other. This is good but it also meant they had fixed minds and didn’t consider other ways of working. Previous stages also needed redundant points securing but these stages had been smaller overall and so the risk surrounding unsecured points was more obvious. Christmas 2016’s work was much greater and so the risk around points was more hidden with the team concentrating elsewhere.
With trust established in the team, a significant amount of communication was done verbally and relied on people would remember what was said and what they’d been asked to do. Team members relied on others confirming that points had been correctly secured. According to RAIB, the team did not appreciate the need to independently check work against its design.
The team’s document management system was hard to use and it seems this was a reason why so much was done verbally. When RAIB comments that the team had difficulty providing documents to the investigators you know there’s something wrong.
Finally, RAIB reveals that over the night before the incident, one person was acting as programme manager, senior manager on duty and project manager. This neutered escalation processes because the various levels to which problems could be raised were all occupied by the same person. RAIB adds that it’s not clear whether this was the result of poor planning or a lack of staff.
There’s a word missing from RAIB’s report. Leadership. Teams need leadership. It is to people what management is to processes. On a busy railway with many passengers and ambitious plans, leadership is vital.

This article first appeared in RAIL 839, published on November 8 2017.


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.