Report 04/2019: Near miss between a train and a track worker at Peterborough

Report 04/2019: Near miss between a train and a track worker at Peterborough, 20 July 2018.

R042019_190605_Peterborough

Summary

At around 10:52 hrs on 20 July 2018, a track worker, who was acting as a site lookout for another track worker who was carrying out an inspection, narrowly avoided being struck by a train near Peterborough station. The train involved had just passed through the station and was travelling at 102 mph (164 km/h) when its driver saw the lookout standing on the same line ahead. The driver immediately sounded the train’s warning horn and applied the brakes. The lookout responded to the train’s horn and moved out of its path about 2.5 seconds before the train reached him.

The investigation found four causal factors. The site lookout was distracted and not adequately observing his distant lookout or looking for approaching trains. He had also chosen to stand on an open line when it was not necessary to do so. The track worker carrying out the inspection, who was also the Controller of Site Safety and responsible for the safety of all the staff involved in the work, was not monitoring the unsafe actions of the lookout at the time of the incident. Lastly, the distant lookout had left his position before the train arrived because he thought he had been stood down. A distant lookout who was visible to the site lookout was from a different team and was looking out for trains coming in the opposite direction.

The investigation also found that the way in which the work was planned defaulted to using the least preferred safe system of work in the hierarchy within Network Rail’s company standard for managing the safety of people at work on or near the line. Further, the current rules for communication when lookouts are used are impractical, leading to a disregard for the rules and the use of unofficial and uncontrolled practices. These two factors were the underlying causes of the incident.

Recommendations

The RAIB has made five recommendations addressed to Network Rail relating to the following areas:

  • a rule change so that site lookouts default to standing in a position of safety unless this is not practicable to implement the safe system of work
  • investigating the common but unofficial use of flag signals by lookouts to communicate, finding ways to improve and control this communication, implementing changes and monitoring the effectiveness of the changes that are made
  • clarifying to track workers the actions they should take when more than one group wants to work with lookouts in the same place
  • continuing the ongoing work of the Network Rail route involved to reduce the use of lookouts for cyclic maintenance tasks
  • reducing the number of cyclic maintenance tasks that are undertaken using lookouts across all of Network Rail’s infrastructure

The investigation also identified three learning points about the importance of early use of the train’s horn by drivers to give an urgent warning, which probably averted an accident in this case; the briefing of lookouts on where to stand while carrying out their duties; and staff responsible for the safety of the work group not becoming distracted by the work activities to the extent that they are no longer observing the group.

Published 5 June 2019