At two minutes to midnight on 10th July 2022, two track workers working close to Penkridge station in Staffordshire had to jump clear of an oncoming train.
The train was travelling at 61 mph towards Stafford when the driver saw the duo standing on the line and sounded his horn. They jumped clear of the track less than one second before the train reached their position.
The details, and lessons, are set out in the Rail Accident Investigation Branch report, Near miss with two track workers at Penkridge,聽 published today.
The incident occurred because the two track workers did not have a recognised safe system of work in place to protect them from approaching trains, the investigators found. The track workers had split off from a larger group to operate an overhead line isolating switch south of Penkridge station. When they left the group, the track workers and the person in charge (PIC) did not reach a mutual understanding of the safety arrangements that would subsequently apply. At the time the train passed, the track workers believed that the line they were on was blocked to the passage of trains, as had been the case when they left the group. The PIC believed that the track workers were standing away from the track in a position of safety, and so he had allowed the line blockage to be removed without warning them.
RAIB鈥檚 investigation found that there was no formal guidance on the arrangements and responsibilities of staff when individuals leave a PIC鈥檚 safe system of work. This was a possible underlying factor. The investigation included consideration of previous investigations and found that there is a widespread acceptance that PICs and controllers of site safety (COSSs) can actively observe and advise their work group on site over a greater distance than is practical or reasonable.
Recommendations
As a result of this investigation, RAIB has made two recommendations to Network Rail. The first relates to the improvement of processes and guidance available to PICs and COSSs to help control the risks when groups split or change during a work activity. The second relates to the practicalities of managing a group on site, and understanding how this can be improved.
RAIB has also identified three learning points relating to the importance of clear communication, the duties allowed to be undertaken by a PIC, and the importance of the availability of train mounted CCTV to assist in safety investigations.
Chief inspector of rail Accidents Andrew Hall, said: 鈥淣etwork Rail has made huge progress in reducing the amount of work undertaken on lines open to traffic. However, the near miss at Penkridge, where a line blockage was being used, is a reminder that working on the track remains hazardous. In this incident, track workers split into two groups, with the person responsible for their safety remaining with one group and no safe system of work in place to cover the revised working arrangement. This was a result of a misunderstanding between the trackworkers and almost cost two people their lives.
鈥淚f a group of trackworkers has to be split, adequate arrangements must be put in place to ensure that the safety of all members of the group are maintained. Communication must be such that everyone fully understands what safe systems of work are in place.
鈥淭his investigation also shows how valuable forward-facing CCTV is for undertaking safety investigations. How close this near miss really was, only became apparent when our inspectors were able to review this vital evidence.鈥�
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