Report 03/2021: Track worker struck by train near Roade

R032021_210609_Roade

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Summary

At around 10:52 hrs on Wednesday 8 April 2020, a passenger train, travelling at 90 mph (145 km/h), struck and fatally injured a track worker on the West Coast main line near the village of Roade, Northamptonshire.

The accident happened because the track worker, who was the person in charge of the work with responsibilities as Controller of Site Safety, was walking along a line that was open to traffic and did not look towards the approaching train on hearing its warning horn. He had gone back onto the track after handing back a blockage of the line, which had been taken to isolate the overhead line equipment, a task which, it was later appreciated, did not need to be done every day. It is not possible to determine with certainty why the track worker decided to walk on the track with no protection, but it is probable he had a purpose in mind and that he believed that no trains were due on the line he was walking along. There is also witness evidence suggesting that he had become habituated to warnings from approaching trains.

RAIB’s investigation found several factors which possibly led to this situation. The performance monitoring and appraisal arrangements for the track worker were inadequate and did not identify and address issues with compliance with rules, standards and procedures. The system of work in place for the site was inadequate for the work being undertaken and did not specify adequate arrangements to encourage compliance with safety rules, possibly affecting the behaviour of the track worker and others during the project. None of the assurance arrangements in place identified any non-compliant behaviours or the inadequate system of work.

Recommendations

RAIB has made two recommendations to AmcoGiffen relating to monitoring and developing the ongoing competence and performance of its staff, and ensuring compliance with its management procedures on new sites of work. One recommendation has been made to Network Rail relating to minimising the need for access to the track when taking isolations of electrical contact systems.

RAIB identified two learning points, relating to track workers only accessing the track when they are protected by safe systems of work, and independent review of safe system of work plans.

Simon French, Chief Inspector of Rail Accidents said:

“This tragic and unnecessary loss of another life was the third fatal accident to track workers that RAIB has investigated in the last three years. This year, in February, there has been yet another, at Surbiton in Surrey.

“Unsafe behaviour on site is a familiar theme. Everyone working on the railway has a responsibility to themselves and their colleagues, which includes not letting dangerous or non-compliant actions go unchallenged. Managers need to be aware of staff behaviour, and the management structure should make it a normal part of their work to be getting out there, and seeing what goes on. It’s all very well to check paperwork, but it’s important to know what is really happening on the ground.

“There still doesn’t appear to be sufficient management focus on what people are actually doing. In this case, the person who was killed was in the habit of walking in the four-foot when he didn’t need to. His co-workers knew he did this- but he hadn’t been picked up on it.

“What makes this even sadder is that the work he had been doing that morning wasn’t necessary: proper planning would have identified that there was no reason for people to go on the track every day during this project to apply and remove earthing straps. We are recommending that Network Rail reviews its processes with the aim of minimising the need for track access in connection with operating the electric traction supply system. I hope that this will help to prevent any more such tragedies.”

Notes to editors

The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.

RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover

matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.

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Newsdate: 9 June 2021