At 14:00 hrs on 13 November 2007 a track worker engaged in a planned track inspection was struck by a passing train on Grosvenor Bridge south of London Victoria station. He suffered serious injuries.
The RAIB investigation identified that the immediate cause of the accident was that the track worker moved away from a line under lookout protection and toward an adjacent line on which a train was approaching. Causal factors were the position where the track worker was walking relative to the lookout, and him not informing the lookout of his intention to move to the other line.
RAIB identified other factors that may have caused or contributed to the accident, including:
- the relationships in the group of staff involved
- the sounding and reaction to the train horn
- the close proximity of bridge girders that restricted access.
Underlying issues concerned the workload of the local track managers, and the documentation of track inspections.
RAIB has also made five observations about related matters that did not directly contribute to the accident.
As a consequence of this accident, RAIB has made nine recommendations, all targeted at Network Rail. These cover the following areas:
- the responsibility of individuals to ensure that they receive adequate safety briefings
- the provision of automatic warning systems
- the use of safety helmets during track inspection
- the effectiveness of processes for confirming ‘on-the-job’ safety performance
- instruction on safe systems of work when trains move on adjacent lines
- documentation for track inspectors
- rebriefing of staff about limited clearance hazards.
Response to recommendations:
- RAIB will periodically update the status of recommendations as reported to us by the relevant safety authority or public body
- RAIB may add comment, particularly if we have concerns regarding these responses.