Rail Accident Report Near miss between a train and a track worker at Shawford 24 June 2016 Report 05/2017 March 2017 This investigation was carried out in accordance with: l the Railway Safety Directive 2004/49/EC; l the Railways and Transport Safety Act 2003; and l the Railways (Accident Investigation and Reporting) Regulations 2005. © Crown copyright 2017 You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned. This document/publication is also available at www.raib.gov.uk. Any enquiries about this publication should be sent to: RAIB Email: [email protected] The Wharf Telephone: 01332 253300 Stores Road Fax: 01332 253301 Derby UK Website: www.gov.uk/raib DE21 4BA This report is published by the Rail Accident Investigation Branch, Department for Transport. Preface Preface The purpose of a Rail Accident Investigation Branch (RAIB) investigation is to improve railway safety by preventing future railway accidents or by mitigating their consequences. It is not the purpose of such an investigation to establish blame or liability. Accordingly, it is inappropriate that RAIB reports should be used to assign fault or blame, or determine liability, since neither the investigation nor the reporting process has been undertaken for that purpose. The RAIB’s findings are based on its own evaluation of the evidence that was available at the time of the investigation and are intended to explain what happened, and why, in a fair and unbiased manner. Where the RAIB has described a factor as being linked to cause and the term is unqualified, this means that the RAIB has satisfied itself that the evidence supports both the presence of the factor and its direct relevance to the causation of the accident. However, where the RAIB is less confident about the existence of a factor, or its role in the causation of the accident, the RAIB will qualify its findings by use of the words ‘probable’ or ‘possible’, as appropriate. Where there is more than one potential explanation the RAIB may describe one factor as being ‘more’ or ‘less’ likely than the other. In some cases factors are described as ‘underlying’. Such factors are also relevant to the causation of the accident but are associated with the underlying management arrangements or organisational issues (such as working culture). Where necessary, the words ‘probable’ or ‘possible’ can also be used to qualify ‘underlying factor’. Use of the word ‘probable’ means that, although it is considered highly likely that the factor applied, some small element of uncertainty remains. Use of the word ‘possible’ means that, although there is some evidence that supports this factor, there remains a more significant degree of uncertainty. An ‘observation’ is a safety issue discovered as part of the investigation that is not considered to be causal or underlying to the event being investigated, but does deserve scrutiny because of a perceived potential for safety learning. The above terms are intended to assist readers’ interpretation of the report, and to provide suitable explanations where uncertainty remains. The report should therefore be interpreted as the view of the RAIB, expressed with the sole purpose of improving railway safety. The RAIB’s investigation (including its scope, methods, conclusions and recommendations) is independent of any inquest or fatal accident inquiry, and all other investigations, including those carried out by the safety authority, police or railway industry. Report 05/2017 March 2017 Shawford This page is intentionally left blank Report 05/2017 4 March 2017 Shawford Near miss between a train and a track worker at Shawford, 24 June 2016 Contents Preface 3 Summary 7 Introduction 8 Key definitions 8 The incident 9 Summary of the incident 9 Context 9 The sequence of events 14 Key facts and analysis 19 Identification of the immediate cause 19 Identification of causal factors 21 Identification of underlying factors 26 Factors affecting the severity of consequences 29 Observations 29 Previous occurrences of a similar character 32 Summary of conclusions 34 Immediate cause 34 Causal factors 34 Underlying factor 34 Factors affecting the severity of consequences 34 Additional observations 35 Previous RAIB recommendations relevant to this investigation 36 Recommendations that are currently being implemented 36 Actions reported as already taken or in progress relevant to this report 39 Recommendations and learning points 41 Recommendations 41 Learning points 43 Report 05/2017 5 March 2017 Shawford Appendices 44 Appendix A - Glossary of abbreviations 44 Appendix B - Glossary of terms 45 Appendix C - Investigation details 49 Report 05/2017 6 March 2017 Shawford Summary Summary At 12:22 hrs on 24 June 2016, a train travelling at about 85 mph (137 km/h) narrowly missed striking a track worker near Shawford station, Hampshire. The track worker and a controller of site safety (COSS) had gone onto the railway to locate a reported rail defect. The track worker was not injured but was badly shaken by the incident. After making an emergency stop, the train driver reported the incident and was fit to continue his journey. The immediate cause was that the track worker had become distracted while he was standing on a line on which trains were running. This happened because there was a breakdown in safety discipline and vigilance when the COSS and track worker went onto the railway. Firstly, they did not implement the required safe system of work for going onto the railway at Shawford. Secondly, the track worker crossed the railway without the permission of the COSS. Thirdly, the track worker was distracted and stopped on an open line when crossing back. The RAIB found a similar breakdown in safety discipline and vigilance when it investigated a fatal accident at Newark North Gate (report 01/2015). It is probable that the track worker’s alertness and decision making were affected by fatigue, because he had slept in his car all week to avoid making long journeys to and from home each day. A possible underlying factor was that the rail testing and lubrication section within the Network Rail delivery unit involved was not resilient to any loss of resources or sudden increase in workload. Although not causal to the incident, the RAIB also observed that the way in which the section carried out safe system of work planning for its staff was not compliant with Network Rail’s processes, and neither the COSS nor the track worker reported their involvement in the incident at the time. In addition to a previous recommendation and learning point from the Newark North Gate accident, which also address the key issue of the breakdown in safety discipline and vigilance in this incident, the RAIB has made three new recommendations, addressed to Network Rail. The first relates to the management of fatigue for staff needing to make long journeys before and after a shift. The second relates to making the rail testing and lubrication section of the delivery unit more able to accommodate a short-term loss of resource and peaks in workload. The third recommendation calls for Network Rail to consider the reasons why its management arrangements on Wessex Route did not detect and rectify the non-compliances with the processes for managing the safety of people working on or near the line. The investigation also identified six learning points about: reminding staff of the importance of following existing rules and procedures; how the early use of the train’s horn by drivers to give an urgent warning can avert an accident if track workers on their line do not acknowledge the first horn warning; and the timely reporting of operational incidents. Report 05/2017 7 March 2017 Shawford Introduction Introduction Key definitions 1 Metric units are used in this report, except when it is normal railway practice to give speeds and locations in imperial units. Where appropriate the equivalent metric value is also given. 2 The report contains abbreviations and technical terms (shown in italics the first time they appear in the report). These are explained in appendices A and B. Sources of evidence used in the investigation are listed in appendix C. Report 05/2017 8 March 2017 Shawford The incident Summary of the incident The incident 3 At 12:22 hrs on 24 June 2016, a train narrowly missed striking a track worker near Shawford station in Hampshire (figure 1). The track worker and acontroller of site safety (COSS) had gone onto the railway to locate a reported rail defect. Location of incident © Crown Copyright. All rights reserved. Department for Transport 100039241. RAIB 2017 Figure 1: Extract from Ordnance Survey map showing location of incident 4 The track worker was not injured but was badly shaken by the incident. After making an emergency stop, the train driver reported the incident to the signaller and was fit to continue his journey. Context Location 5 The incident occurred to the north of Shawford station on the down fast line between Winchester and Eastleigh (figure 2), at about 69 miles 440 yards (from a zero datum at London Waterloo station). The line is part of Network Rail’s Wessex Route and at this location the railway comprises three tracks: the up main, down