On the night of 23 May 2008, a First Great Western passenger train travelling from Paddington to Oxford struck and seriously injured a Network Rail signalling technician who was working on a set of points at Kennington Junction, Oxfordshire. As a result of the injuries received, the technician later had one leg amputated. There was no damage to the train or railway infrastructure.
The immediate cause of the accident was that the signalling technician failed to move to a position of safety when the lookout warned of an approaching train.
Significant factors in the accident were:
- inadequacies in the briefing and implementation of, and compliance with the proposed system of work
- staff working with an inadequate system of work for times of darkness
- managerial acceptance of the practice of maintaining points while trains were still permitted to run
- a lack of clear guidance in the Rule Book and other publications about safe working practices when trains could pass on adjacent lines.
RAIB has made several recommendations after previous investigations that are relevant to this incident, but has not repeated them as they are still being dealt with by Network Rail and the Office of Rail Regulation. However, RAIB has made three new recommendations two of which are targeted at Network Rail, whilst one is targeted at Network Rail in conjunction with the Rail Safety and Standards Board. These cover the following areas:
- investigating the adoption of alternative working methods when maintaining points
- providing improved guidance on when to use the various means of protecting staff from moving trains
- providing guidance on the meaning of the terms used in the Rule Book and other publications such as ‘affect the safety of the line’, ‘affect the safety of trains’, ‘affect the safety of train working’, and ‘affect the normal passage of trains’.
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