Image credit: ORR
A collision between two railway maintenance vehicles that left one worker with life-changing injuries has resulted in a £1.4 million fine for Network Rail. We look at how it happened.
At about 2.30 in the morning of 19 September 2018, on a stretch of railway track between Crewe and Chester, a 25-tonne ‘Superboss’ ballast distributor collided with a lightweight Kubota people carrier that was transporting maintenance workers. Two employees were injured as a result – one of whom had life-changing injuries – and Network Rail faced prosecution, culminating in a £1.4 million fine.
But while those are the headline facts, for health and safety professionals, it’s the details that are crucial in understanding how the accident came about. We spoke to HM Inspector of Railways Alexandra Brocken from the Office of Road and Rail (ORR) about how such an event could occur.
'This incident happened in the course of overnight maintenance works during a ‘possession’ – that’s the term we use in the rail industry when the railway is closed to normal traffic for engineering work,' Alex said.
'The ballast distributor was delivering ballast to two sites about a mile apart. The ballast was needed to correct a fault where the track was out of its normal track geometry and ballast was needed to lift the rail to the correct level.
'What should have happened is that the people working on the line should have been at the furthest of the two sites from the rail access point. The ballast distributor was supposed to travel to them, deliver the ballast and then head back to the site nearer the rail access point. The guys on the Kubota would then have packed the ballast into place before they too would have moved to the second site.
'Various failures happened, one of which was that there had been a delay of about an hour and a half getting the ballast distributor on site – it had had a brake fault that required a fitter attending it earlier in the night. Because of this delay, the team in the Kubota people carrier decided to move from the site furthest away to the slightly closer site without getting authorisation to move.
'The normal railway signalling system is suspended in a possession, so all plant movements should be closely monitored and authorised by an engineering supervisor. The ballast distributor driver thought the team was still at the furthest site. When the ballast distributor set off, it also did so without authorisation, so nobody knew where either of the machines were.'
The collision
The ballast distributor was travelling in reverse. However, there is a restricted view from the operator’s seat when travelling in reverse, so a ‘machine controller’ – a banksman type machine minder – is supposed to walk on the ground near the machine whilst it is travelling so that they can direct the operator by radio headset and watch out for hazards. This effectively limits the speed of the machine to walking speed, but the general speed limit is 5mph.
'In this case, the furthest of the two sites of work was around four miles from the access point. To save time and to avoid the personal safety hazards of walking that distance on the ballast at night, a local workaround had developed in which the machine controller would ride in the cab of the machine until about 300 yards from the site of work, then the machine controller would get out and direct the operator from the ground for that last part of the journey,' said Alex.
However, the ballast distributor never reached the site.
'The ballast distributor was travelling in excess of the permitted speed limit – we estimated that on this occasion, the ballast distributor was travelling at about 10-15 mph – and because the machine controller was riding in the cab, it was being driven blind. Those are two significant factors before you add the fact the works team had made an unauthorised movement and come a mile closer,” she added.
'As the ballast distributor unknowingly approached the team, there were two people sitting on the back of the Kubota. These were the two people who were injured. One man saw a collision was imminent and jumped over the side rails of the Kubota. In doing so, he got minor injuries to his shoulder and a fracture to his wrist.
'The other person stood up but he wasn’t quite as quick or agile, and he suffered significant injuries to his legs and spine when he was crushed between the two vehicles. Following hospital treatment, he lost 12cm of bone to his left leg and 4cm to his right leg. The tendons and nerves of his right leg were also irreparably damaged, causing permanent disability. In the three and a half years since the accident, he has had a series of surgeries but he is very restricted physically and his whole life has been turned upside down.'
The investigation
For Alex, the confusion that played a role in causing the accident also made investigating what happened a little more difficult.
'The problem was that there was a number of failings at different layers: among the staff and supervisor management on site; at first-level line manager assurance level; and there were failures almost all the way up – failures in planning, briefing, giving proper instruction and information to staff,' said Alex.
'One of the main problems we faced was that nobody really understood where they were supposed to be working because they hadn’t had a thorough briefing. So when interviewing witnesses, we faced the situation where one person was telling us what they thought they should have been doing and the location they thought they should have been at, but then the next person would tell us something different. Because one of the factors that went into causing the accident was confusion around the task, it was then difficult to pick away everybody’s conflicting evidence and try to draw the facts out of it.
'In that depot, everybody is very friendly with each other. It’s quite small, a lot of people are related, and those who aren’t literally related might as well be brothers because they’ve worked together for decades – everyone is very close. With that, over time, there came a culture that isn’t ideal for safety,' she said.
'We have a safety-critical communications protocol on the railway that is very formal in terms of the language that has to be used, but you might feel a little daft using that language with your brother or best mate. So the culture in that depot had deteriorated over time to support a type of non-deliberate rule breaking – the workers saw it as just the way that they do it, and particularly with their local workarounds, they felt they’d never get the job done otherwise.
'One important thing to note is that Network Rail did have risk assessments and it did have procedures, they just weren’t being followed. There was simply a poor safety culture in this particular depot: a longstanding culture of not following the rules and local workarounds that had become normal custom and practice. Network Rail has a whole suite of control measures in place so that high-risk machinery like this can be used to do high-risk activities. But it’s important that staff are following those procedures – and that didn’t happen in this case.'
The prosecution
Although the incident came about as the result of a catalogue of errors by individuals, the decision to prosecute Network Rail was quite straightforward.
'In this incident, every safety-critical member of staff made errors. Had it been a case of just one individual making a deliberate errors, then perhaps the investigation would have taken a different focus. But because every single member of safety-critical staff had made failings that night, we had to start looking at the system and see where it failed,' explained Alex.
'It turned out that there was a lack of supervision, competency issues and a lack of instruction. We came to the conclusion that the assurance system wasn’t robust enough to have identified long-standing issues that lead to the poor safety culture and local workarounds. No-one was supervising, and the team didn’t get the right instructions. It was a systemic fault and the legal entity with the most responsibility for controlling the work in the first place, and the entity most able to make changes and improvements for the future was Network Rail.”
At its prosecution at Chester Magistrates' Court, Network Rail pleaded guilty to breaching sections 2(1) and (2) of the Health and Safety at Work Act. It was fined £1.4 million and also ordered to pay prosecution costs of £63,118 to ORR.
'That level of fine reflects the severity of the injuries but also the level of responsibility that Network Rail had and the level of risk that was involved. It’s down to the judge to decide on the fine amount; the important thing for ORR is that Network Rail has been held accountable. More importantly, Network Rail has also learnt lessons, it’s made its own improvements, and hopefully there won’t be similar occurrence again in the future,' Alex noted.
Key learnings
So what clear lessons can OSH professionals outside the rail industry take from an incident that was effectively the result of a series of errors?
'The first thing is to understand that this was an easily preventable accident that could have been avoided with proper planning. In this incident there were a lot of late changes – that’s not unusual, there are lots of late changes all the time working on railways, it’s a dynamic situation – but work has to be planned so that there is capacity to take and accommodate late changes, and they need to be clearly communicated to everyone involved,' Alex said.
'You also have to have the correct staff availability. You need competent people in the right roles. Remember that competency doesn’t just mean they have been in a classroom course for the necessary amount of time: they have to have the skills and knowledge, and they have to understand the responsibilities of the job in hand. They need adequate experience and general ability beyond just going on a course.
'Then communication is crucial. In this case, the late changes weren’t communicated consistently to everybody and there was confusion over who was in which location, and where and what the work was supposed to be. Safety critical communication is key to many railway activities. It is also important to supervise staff effectively so that people follow the instructions they have been given. Organisations should regularly audit themselves to make sure their people are consistently following the instructions and processes that control safety risks.
'Ultimately, this was a case that could have been avoided if Network Rail had made sure everybody knew what they were supposed to be doing, where they were supposed to be doing it, and following the correct processes.'
