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Sledgehammer, nutcracker

Accidents happen - that’s a fact of life. Disarming every threat - conceivable or otherwise - is neither possible nor desirable. We could ban corners, heights, slippiness and lingerie advertisements, then spend our lives in bed, but we’d still be susceptible to meteorite strikes.

Corporate fear has become the biggest driver when it comes to health and safety management; that and the often cancerous enforcement approach of regulators. Pragmatism and logic have been deemed too dangerous. Every mishap brings with it a fresh onslaught of madness dreamt up by the ignorant. Rarely is the response proportionate; often it’s simply unworkable.

Torworth level crossing - lights flashing, barriers down.
Photo: Roger Geach

On the evening of Saturday 8th January 2011, a tamper driver had a close encounter with a 100mph passenger train on the East Coast Main Line in Nottinghamshire. On the basis of visual cues, he had concluded that the line he was walking on was blocked when in fact it was open. Struck a glancing blow, he suffered minor injuries and was off work for 18 weeks: a positive result given the event’s potential. But there have been longer-lasting consequences for those fulfilling similar roles across the industry. And instead of safety benefit, they bring only aggravation.

Employed by Colas Rail, the tamper driver was attached to its track renewals unit (known as System 4) based at Willesden in North London, but on this occasion he had volunteered to work an overtime shift for System 3 in Doncaster due to staff shortages. Six days before the job he received an email detailing the location of the site access cabin at the old station in Bawtry, the booking-on time, and the phone number of the driver who would take the machine to the worksite from Doncaster Wood Yard. These arrangements subsequently entered a state of flux without the tamper driver being notified; he learnt of the changes by chance.

At around 23:00hrs on 8th January, he left the hotel in Doncaster where he had been resting prior to his shift. He’d only managed two hours sleep thanks to a raucous wedding party. The email - which he had been unable to print due to a fault with his home printer - only included a partial postcode for the site cabin, resulting in SatNav problems. He drove around Bawtry for a few minutes before seeking guidance from his fellow driver on the tamper who was already in the worksite. The latter considered it easier to direct his relief to Torworth level crossing, close to where the machine was at a stand. The tamper operator was given similar instructions when he called. Consequently neither signed in at the site cabin.

It was 23:50hrs when the tamper driver eventually arrived at the crossing; he’d got lost and ended up in Retford. Now 20 minutes late, he parked his van by the roadside, donned the relevant PPE and walked towards the crossing carrying a bag over his right shoulder. The barriers were down and the lights flashing. Stationary on the furthest line (the Up Main) was the back end of a high output ballast cleaner (HOBC). He looked both ways to confirm nothing was coming on the nearest line (the Down Main), then walked northwards in the four-foot with his back to the normal direction of traffic. A point motor and cabling served as a deterrent to using the cess.

He was about to step across to the Up Main, beyond the trailing locomotive of the HOBC, when he heard a train horn. Looking back he saw 1D53, a late-running London-to-Leeds service, approaching at 100mph. As he tried to move clear, he was struck a glancing blow and thrown forward into the four-foot of the adjacent line. Torn from his shoulder, the bag was later found wrapped around the off-side step of the leading cab. An ambulance was summoned which he was able to walk to. Following three hours treatment the hospital discharged him.

The view north from the crossing with a point motor in the Down cess.
Picture Source: RAIB Rail Accident Report (Crown Copyright)

That night’s activity had been the subject of a whiteboard meeting earlier in the week; a work package plan and task briefing sheet had been generated; there was a safe system of work pack with all the prescribed documentation. However no-one considered the safety implications of having an imported tamper crew with no local knowledge; they were left out of the communications loop. This accident occurred despite blind compliance with all the procedural gloop, demonstrating how systemically flawed it is.

But there was nothing exceptional about the accident’s preceding events. It has never been custom and practice for drivers to sign in or receive a briefing before entering a worksite, either on foot or aboard their train. Under Rule Book module G1, they are perfectly entitled to walk alone on-track providing a handful of basic instructions are observed and sufficient information has been gleaned, such as the speed and direction of trains.

And that was the failing here: the tamper driver made an errant assumption based on the evidence in front of him. The key learning point is that anyone entering the operational railway under their own protection must regard all lines as open - and act accordingly. It’s as simple as that…except of course it never is. Irrelevant is the fact that hundreds of drivers have walked harmlessly to their trains on many thousands of occasions previously. Health and safety demands that the baby is thrown out with the bathwater.

RAIB points a finger at the casualty for missing the opportunity to receive safety information by attending the site cabin. This of course is a red herring: a site access controller cannot tell you whether a line is blocked - in a worksite, only the Engineering Supervisor can confirm that. Neither can he brief you on the specific route to site and associated hazards - that requires a COSS. Quite how this man would have been spared injury by knowing the location of the toilet is not described in the inquiry report.

If he had been furnished with the contact details of on-site staff he could have phoned someone for a safety briefing, asserts the Branch’s investigator from his asylum in Cloud Cuckoo Land. Perhaps the driver’s mum could have helped, assuming she was back from bingo. What about Brenda - barmaid at the Duck & Puddle? Usually besotted with minutiae, RAIB is apparently happy to endorse the seeking of safety critical advice from a faceless stranger whose knowledge and competence can’t be verified. Despite existing for seven years, it can still be guilty of shocking aberrations and has yet to gain any insight into the culture of rail workers.

And so the throttling noose of risk aversion contrives a tighter grip. AmeyCOLAS, a joint venture comprising Colas Rail, is now actively enforcing a policy that all staff on duty within a worksite - including drivers - must sign in both at the site cabin and with a COSS. Non-compliance will lead to disciplinary action. Spend a few moments considering the logistical implications of this in long worksites and where engineering trains originate from far-flung locations. Site access controllers have been given a script to ensure they regurgitate with consistency a babbling stream of trivia, making sure workers have their minds numbed before going trackside.
And so the throttling noose of risk aversion contrives a tighter grip.

A documented process for train drivers, ground crew and on-track machine operators has been established by Network Rail involving the distribution of a flowchart to relevant organisations. This demands the provision of a briefing at the site cabin when accessing on foot, or at the entrance to the worksite if arriving by train. Scientists are progressing well with a cloning programme to facilitate this. A similar regime, in the form of a Code of Practice, was devised in 2007 - and later accepted by the ORR - but nobody bothered to circulate it beyond members of the Infrastructure Safety Liaison Group (ISLG). Very few companies knew of its existence. What a fabulous indictment of the industry’s tick-box culture: develop paperwork, forget implementation.

RAIB’s contribution has been to recommend a review of how best to provide drivers with relevant information about the risks they might face within the worksite, including site briefings, additional training, the production of printed materials and amendments to the relevant rules.

Of course none of this would have prevented the accident at Torworth. Even if he’d visited the site cabin to be told how dangerous a kettle can be, would the tamper driver have acted any differently when he walked onto the railway that night? Don’t allow the wool to be pulled over your eyes - the changes outlined above are not being imposed to make anyone safer. They won’t, just as the 2007 Code of Practice didn’t. Their purpose is to distract enforcement agencies through the illusion of mime: look as though you’re taking action by wafting a lot of fog around.

Compliance with basic rules would have averted this accident. Harsh but true. The tamper driver should have treated the Down Main as open: that’s what his training told him. Imposing unnecessary, onerous and time-consuming activity on the industry when it’s under pressure to drive up efficiency will only make life harder and spread resources more thinly. And it doesn’t take a genius - or a safety professional - to recognise the potential implications of that.

Story added August 2012

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