Network Rail has been handed another multi-million pound fine after two workers were fatally struck and a third narrowly missed being hit by a train while undertaking track maintenance in south Wales in 2019. The Office of Rail and Road (ORR) investigation found that Network Rail’s failure to protect the three maintenance workers operating on or near the line from passing trains reflected similar failures identified in ORR inspections in 2018 and 2019 and other previous incidents where fatalities and/or near misses had occurred.
Network Rail employees Michael Lewis, Gareth Delbridge and a third (unnamed) worker were undertaking track maintenance on a set of points at Margam East Junction, near Port Talbot, south Wales on 3 July 2019 when a Great Western passenger train travelling at about 50 mph fatally struck Lewis and Delbridge around 9.52am. The third worker narrowly escaped being hit. The three workers were part of a team of six that was undertaking ‘red zone’ working, which is when rail lines remain live while maintenance is completed.
The Rail Accident Investigation Branch (RAIB) concluded from its investigation that the tragedy occurred because the three track workers were operating on an open line, but without formally appointed lookouts present to warn them of approaching trains.
Network Rail also chose not to put in place a line block, which would have prevented trains from travelling on the track section the trio was undertaking maintenance on.
In its report, published in November 2020, the RAIB concluded that all three men were almost certainly wearing ear defenders because one of them was operating a noisy power tool and all were 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,’ noted the report.
‘Subsequent acoustic measurements have shown that they would not have been able to hear the train’s warning horn.’
What failings were uncovered?
When the RAIB investigated the incident, it found systematic and wide-ranging safety failures that were directly caused by inadequacies in Network Rail’s processes and management systems.
Its report noted that the system of work that Network Rail’s controller of site safety had proposed to implement before the work began was not adopted. To compound matters, ‘the alternative arrangements became progressively less safe as the work proceeded that morning and created conditions that made an accident much more likely.’
RAIB also highlighted several contributing factors that led to this situation, which related to the work itself; 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. In addition, the investigation also looked at why Network Rail had failed to create the conditions that were needed to achieve a significant and sustained improvement in track worker safety.
Four underlying factors are outlined in the RAIB’s report:
– Over a period of many years, Network Rail had not adequately addressed the protection of track workers from moving trains. 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.
Network Rail pleaded guilty to a single breach of section 2(1) of the Health and Safety at Work Act. Recorder Christian Jowett fined the business £3.75m and ordered it to pay £175,000 in costs at Swansea Crown Court.
According to the BBC’s report , Jowett described the workers’ protection as being the ‘lowest level’. ‘Visibility towards Port Talbot at the site was restricted due to a curve in the track, so the need for two lookouts was identified, with four men carrying out the work,’ he said. ‘But what happened was the group split into two, one to carry out the maintenance work and the other to carry out [other] work – [so] no one was available to be the second distant lookout.’
Responding to the sentencing, Nick Millington, route director for Network Rail Wales & Borders, said: ‘We know that the tragic deaths of our colleagues, Gareth Delbridge and Michael “Spike” Lewis, should never have happened on our railway and that has been reflected by today’s judgment. ‘Over the last five years I have met regularly with Gareth and Spike’s families and our thoughts remain with them, and all those friends and colleagues who have been impacted by their deaths. ‘Since this tragedy, we have continued to transform the safety of our workforce through the development of new technology and planning tools, which have almost entirely eliminated the need to work on the railway when trains are running. ‘Today’s judgment reinforces why safety must always be our first consideration, and we will continue to do all we can to make our railways the safest they can be.’
What has changed since the tragedy?
Following the publication of its report in November 2020, the RAIB made 11 recommendations, nine of which were directed at Network Rail.
These included requiring the business to:
– Improve its safe work planning processes and the monitoring and supervision of maintenance staff (three recommendations).
– Renew the focus on developing the safety behaviours of all its front-line track maintenance staff, their supervisors and managers.
– Establish an independent expert group to provide continuity of vision, guidance and challenge to its initiatives to improve track worker safety.
– Improve the safety reporting culture.
– Improve the assurance processes, the quality of information available to senior management, and processes for assessing the impact of changes to working practices of front-line staff (three
recommendations).
SOURCE – IOSH
