Never has communication been so easy. Ones and noughts - and the technology to pull them through copper and fibre - have brought 620 million websites within reach of our homes and offices. And today we’re data-rich on the move too, thanks to the computers in our pockets. We’ve witnessed a revolution over recent years that has transformed the way we live our lives. But before phones became smart, we used to speak to one-another. Remember that? It’s a cultural shift that has given rise to its own challenges.

Stoats Nest Junction is a busy spot on the main line from London Victoria to Gatwick, where the Slow and Fast lines come together in a series of crossovers. Early on the morning of 12th June 2011, the crossing of 1666A points - forming one end of the connection between the Up Slow and Down Fast - was being replaced by a ten-man gang. Based at East Croydon permanent way depot, they comprised the local Section Manager (Track) and Assistant Section Manager (Track), two COSSs and six other men. The SM - a man with 37 years of railway experience - was father of the ASM who had been in the industry for nine years. One of the COSSs was overseeing the crossing work while the other looked after the RRVs used for transporting the materials.

Possession and isolation of the Up and Down Fast lines had been secured by 01:15hrs; the Up Slow was added at around 01:55hrs. In both cases, this was later than scheduled - by how much is not stated in RAIB’s report. The Down Slow remained open, with single line working introduced over it. The block extended southwards from Purley to Balcombe Tunnel Junction on the Fasts (about 18 miles) and Redhill on the Up Slow (nine miles). Several worksites were accommodated, with tamping, stoneblowing and rail head repairs all featuring.

A busy scene at Stoats Nest Junction, with the crossover between the Down Fast and Up Slow lines obsured by the signal post centre-right. Photo: Steve Poole

At Stoats Nest Junction, the track gang began by cutting out the cracked crossing; meanwhile RRVs brought the replacement to site from Purley, as well as two closure rails. Unfortunately one of these rails was found to be too short so another had to be sourced. This, coupled with the delay in obtaining the possession, meant that it would no longer be possible to weld this closure rail into place; clamps would be used instead.

The Up Slow was due to be returned to traffic at 05:15hrs and the relevant processes got underway at about 04:30hrs. When the Engineering Supervisor rang the COSS at 04:47hrs to gauge progress with the work, the COSS informed him that he was no longer at the site, having been despatched to remove equipment set up for a Temporary Speed Restriction. As a result, the ES then rang the ASM. At 05:09hrs and contrary to the rules, the ASM - rather than the COSS - assured the ES that the Up Slow could be handed back; this was despite work still continuing. The possession was given up eight minutes later. At 05:24hrs, an on-train camera recorded members of the gang standing in the four-foot of the now-open Up Slow.

A little earlier at 05:08hrs, a Victoria-bound train was sitting in the platform at Redhill, six miles further south. The driver had been expecting a pilotman to accompany him in the Up direction over the Down Slow but the signaller advised him that he would be routed along the Up Slow as the possession was being withdrawn. The signal cleared. Twenty minutes later, the train was approaching Stoats Nest Junction at 77mph. The driver applied the brake while he checked his schedule card to confirm whether he was booked to stop at Purley. When he looked up again, he saw members of the gang close to the Up Slow. He sounded the horn using the ‘soft’ setting. No-one on site heard it due to a cacophony of equipment noise.

Two of the gang were crouching next to the track and were narrowly missed by the train’s bogies. The SM and ASM were between the Down Fast and Up Slow, beyond the closure rail, with their backs to the approaching train. Now travelling at 60mph, it struck the Assistant Section Manager at around shoulder height, throwing him forwards onto the Down Fast and causing serious injuries to his head, shoulders and torso. He has since made a full recovery.

RAIB’s inquiry found that no safe system of work had been implemented to protect the workgroup from trains on the reopened Up Slow. Such duties clearly fell to the COSS - and sufficient resources, in the form of qualified lookouts, were available to him - but he was not on site when the line was handed back. As a result, most members of the group remained unaware that the possession had been lifted. Only the SM and ASM were in the know: they had activated the arrangements for giving up the possession.

The COSS subsequently asserted that his involvement in removing the TSR equipment was instigated by the Section Manager, who had mentored him in the COSS role a few months earlier. His unquestioning compliance was a function of the SM’s loftier designation. Another competent person should have taken over, however this would have involved phone calls and bureaucracy. For whatever reason, it didn’t happen. Time was against them.

The Engineering Supervisor - who tested positive for recreational drugs three days after the accident - was aware that rules were being broken at Stoats Nest Junction. Despite this, he didn’t question the authority of the SM and ASM, who were his line managers, and accepted the latter’s assurance that the line was clear and safe for trains to run. He has since resigned. Both the SM and ASM have also left Network Rail.

What’s apparent here is that the behaviour of the relative juniors performing safety-critical duties was adversely influenced by the presence of their superiors who were making their presence felt. Without any suggestion of intent, this change in the group dynamic introduced conflicts that no-one felt able to challenge.

Since an accident with similar undertones at Ruscombe in February 2008, Network Rail has developed processes to assess the necessary behaviours of COSSs and team leaders. This work became part of a wider national initiative dealing with safety culture. Although some modifications were made to selection criterion and training programmes for staff taking on new roles, the changes aimed at existing competency holders had not been delivered by the time of the accident at Stoats Nest Junction.

RAIB clearly believes this is significant. I don’t. In the overwhelming majority of cases, no amount of briefing-room fluff would cause a minion to question the actions of their boss, particularly when the clock is ticking ever louder. Nevertheless, Network Rail’s slow rate of progress in effecting cultural change amongst trackworkers is criticised by the Branch, expressing concern that “it has taken the industry so long to address safety behavioural issues that were identified in a number of RAIB recommendations published since 2006.” Perhaps if the Branch had not exceeded the statutory timescales for completing its inquiries on quite so many occasions, Network Rail might have learnt lessons more quickly. This is pure hypocrisy! The Stoats Nest inquiry took RAIB 14 months; NR issued a safety bulletin about the accident a day after it happened. I’ll leave you to draw your own conclusions about comparative institutional shabbiness.

In terms of recommendations, the best the Branch can offer is to reaffirm three from previous inquiries, relating to the selection of those chosen for safety-critical roles and the commissioning of yet more human factors research into workgroup culture. That’ll sort it out. Its only accident-specific offering is to demand “full implementation of processes intended to ensure that managers do not undermine the safety-related responsibilities of Controllers of Site Safety.” Great!

The inquiry report provides no analysis of the impact of any time constraints resulting from the late granting of the possession, nor does it identify this as a contributory factor. In fact, it doesn’t even give the time at which the PICOP was authorised to start making the arrangements. Was it two minutes late, or 52? Who knows? Readers are told only that the Fast lines possession was booked from 00:05hrs but was not fully in place until 01:15hrs. The Up Slow was added at 01:55hrs, having been booked from 01:05hrs. Surely this is important. If there had been sufficient time to find a replacement closure rail and complete the work (perhaps with clamps rather than welds) while the possession was in place, the accident would not have occurred. It was probably the looming deadline that drove the non-compliances. But this clearly didn’t bother the investigator, or perhaps it just never occurred to him.

Instead of reflecting on its own failings, RAIB stands in its glass house throwing stones. None of the major players come out of this accident with any credit - neither individuals nor organisations. But its inability to get under the skin and examine what it finds with a practical eye shines a bright light on the Branch’s shortcomings. In an era of easy communication, RAIB excels in making it look very difficult indeed.