Important safety messages
According to the safety digest, the incident demonstrates the importance of:
The incident
At about 05:51 hrs on Wednesday 17 January 2018, three signalling technicians were involved in a near miss with a train while they were working on a set of points near Clapham Junction station, south-west London. The technicians were diagnosing a fault on a machine that operates the points, which is situated in the space between two adjacent railway tracks – the Up Windsor Slow line and the Up Windsor Fast line. Although the Up Windsor Slow line had been blocked to carry out this work, the train passed on the Up Windsor Fast line, which was open to traffic.
The train involved was the 05:17 hrs South Western Railway empty coaching stock train from Wimbledon Park Sidings to London Waterloo. It was travelling at a speed of about 42 mph (68 km/h) at the time of the incident.
The driver sounded the horn about five seconds before reaching the group of technicians, and then applied the emergency brake at almost the same time as he passed them. One of the group heard the approach of the train and shouted a warning to his colleagues. They started moving clear of the train about two seconds before it passed them.
Nobody was injured, but the three technicians and the train driver were badly shaken by the incident.
Cause
The incident occurred because the technicians were working in a location where they were not protected from moving trains. The system of work that they had set up was arranged so that the Up Windsor Slow line provided a position of safety for them, but this safe area did not extend to the space (known as the six-foot) between that line and the Up Windsor Fast line. Consequently, to work in that space would have required a change to the system of work to provide protection from train movements on the Up Windsor Fast line.
All of the group were experienced on the railway and held a number of relevant competencies. They were all aware that only the Up Windsor Slow line had been blocked, but their initial assumption was that the work would not involve straying outside the protection provided by that line. By the time it became clear that they would need to work on the points machine itself (ie between the blocked line and an open line), they had all become engaged in the task and lost awareness of the fact that the Up Windsor Fast line was still open.
Following the incident, Network Rail issued a bulletin across its Wessex route reminding staff of the need for a suitable and valid safe system of work at all times, including a reassessment of the protection arrangements when the nature of the anticipated work changes.
An example of the pressure to “get the job done” affecting people’s train of thought (excuse the pun) and safety being pushed down the focus list.
Too much reliance of ticking boxes and no enough active safety management. People have become to used to just ticking checklists without questioning if measures are fit for purpose.
Scott, nowhere does the report indicate pressure to get the job done was a causative factor? To me, it’s a case of poor situational awareness (SA), which is one of the non-technical skills promoted by the rail industry. If they knew only one line was blocked, it is clear that the other has the potential for traffic and as such, this should have been considered and managed. Experience can lead to complacency, which is where SA by all personnel is crucial in dynamic risk management. The report doesn’t lay any blame at management, as the team were managing their own… Read more »
This incident shows the danger of carrying out the job planning – risk assessment & method of work – remotely. There seems to have been no review of the controls in place before starting work and no poinr of work assessment carried out. Thankfully, serious injuries were avoided.