At 09:31 hrs on 6 August 2012, train 2W06, the 09:25 hrs service from Nottingham to Worksop, struck and seriously injured an off-track inspector on the up-down Mansfield line near to Bulwell station, in Nottingham. At the time of the accident, the off-track inspector was undertaking an inspection of lineside vegetation on foot.
The off-track inspector was struck by the train because he was standing too close to the track. His awareness of where he was standing had become reduced as he was focused on determining his location. It may also have become reduced because he needed to concentrate on some elements of the inspection.
Because the off-track inspector was working on a line open to railway traffic, he had implemented a pre-planned system of work to protect himself from train movements. However, this system of work was unsuitable for the location and task being undertaken. Had the most appropriate type of system of work been planned and implemented, then the accident would have been avoided. The off-track inspector did not realise that the system he was using was unsuitable during the inspection, probably due to the way in which it was implemented. He had also not realised it was unsuitable when the system was issued to him prior to the inspection; this was because the information provided to help him check that it was appropriate did not effectively highlight why it was unsuitable.
This system of work was issued to the off-track inspector because the planner who had prepared it was unfamiliar with the location. Information provided to support her decisions about which type of system to use either did not effectively highlight its unsuitability or was found by her to be impracticable to use given her workload.
In addition, it had become normal practice within the off-track section to plan and implement the least protective type of system of work for undertaking vegetation inspections. This was, in part, because the section only had a limited range of systems to choose from, but probably also because there was an informal agreement within the section to adopt this practice, which contravened the requirements of Network Rail’s standards. Senior managers were unaware that this had occurred as they were provided with inaccurate safety monitoring data. The increased workload of planners within off-track sections was also identified as a factor in the accident.
The RAIB has identified two key learning points. These are: that the relevant Network Rail standard should be observed during the planning, approval and verification of systems of work; and that any incident where a train has struck something whilst passing persons working on or near the line should be initially treated as an accident.
The RAIB has also made five recommendations addressed to Network Rail. These relate to: the provision of information to staff about which systems of work have been found to be appropriate for given locations; the monitoring of which system of work types are being used; the resources available within off-track sections to plan and approve systems of work; how previous measures taken by Network Rail to improve the management of systems of work were implemented; and the provision of information to staff regarding the required warning times when working alone.
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.