At around 01:00 hrs on 24 June 2008, three members of a rail-grinding team were standing with two rail-mounted grinding machines on the up relief line east of Acton West Junction, waiting permission to push the machines towards Ealing Broadway station.
Train 2P01, the 00:15 hrs First Great Western service from Reading to London Paddington, ran through the crossovers at Acton West onto the up relief line and struck the machines. The three members of the grinding team scattered as the train approached.
Nobody was injured in the collision, but the train suffered damage to braking equipment and a punctured fuel tank on the leading coach. The 25 passengers on the train were evacuated safely.
The RAIB investigation identified that the immediate causes of the collision were:
- that the grinding machines were placed on a section of railway that was open to train operations
- that neither the person responsible for the safety of the track workers nor the person who planned their safe system of work had adequate geographical knowledge of the Acton area.
- The format of the safety information provided to the people working on the site was confusing, as it did not contain track layout diagrams; and was presented in an inconsistent format
- The person responsible for the safety of the track workers on site did not check the detail of the safety information provided
- A key member of staff on site who may have had an opportunity to identify the error that was about to be made did not do so; this was because he was distracted by having to perform a number of tasks at the same time
- There were weak management arrangements in place at the track workers’ home depot, which permitted non-compliances with Network Rail’s procedures for securing the safety of staff on site
- London-area planning meetings in Network Rail’s Western route did not discuss access arrangements for staff working on site, despite being mandated to do so by the company’s own procedures.
As a consequence of this incident, RAIB has made eight recommendations, all targeted at Network Rail. They cover:
- the need for planning and site staff to have geographical knowledge of area where they work
- changing the methods used for preparing safe systems of work and the format of the information provided
- provision of site layout information at track access points
- achieving an equitable balance of work between safety-critical staff on site
- ensuring that possession planning meetings address site access arrangements
- reviewing audit arrangements to identify how Network Rail’s non-compliances with its own procedures were overlooked.
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.
Published 10 December 2014