Summary
At around 10:57 hrs on Saturday 25 January 2020, a mobile elevating work platform (MEWP) collided with a stationary machine of the same type on which two people were installing overhead line equipment. They both suffered minor injuries. The machine operator in charge of the MEWP had lost focus while driving the machine, and was alerted by other members of staff shouting at him to stop. At that point the machine was travelling too fast to stop before striking the stationary MEWP. The machine operator had driven away from the machine controller, who was responsible for the MEWP's movements, without permission, and drove the machine at around 10 mph (16 km/h), while using the on-board CCTV screen to view the route ahead. These actions were contrary to the applicable operating rules.
Other causal factors were ineffective supervision of the machine operator and confusion among staff about who was in charge of the safe movement of on-track plant on the site. Cultural factors on the site led to poor working relationships between machine operators and controllers and an excessive focus on 'getting the job done', rather than compliance with rules and operating standards. Network Rail's assurance processes had not identified these issues.
Recommendations
RAIB has made five recommendations, each addressed to Network Rail. The first is to review and clarify the roles and responsibilities of staff working in possessions and work sites to avoid duplication of responsibilities and confusion arising between roles. The second recommendation is that Network Rail should undertake a review of the way that the Sentinel scheme is managed, in respect of incident investigations and how training providers and primary sponsors assess the English language skills of staff who undertake safety critical duties.
The third recommendation is addressed to Network Rail (Anglia), to review its reporting and response process for accidents and incidents, and the fourth recommendation seeks a review of the equipment currently used to alert staff to a dangerous situation within a possession or work site. The fifth recommendation is to commission an independent review of the internal culture and working practices of Network Rail's Overhead Condition Renewals business unit. The investigation also identified five learning points.
Simon French, Chief Inspector of Rail Accidents said:
Although the consequences of this accident were minor, the people who were in the machine that was struck could easily have been killed if they had not been wearing their safety harnesses.
Our investigation found a catalogue of errors and omissions which could have had much more serious consequences. We found duplicated lines of control, leading to confusion and a lack of clarity about who was in charge of the work and the machinery that was being used. As well as the safety risk this creates, it's also inefficient and wasteful. Network Rail needs to find a more effective way of managing the movements of multiple vehicles in work sites.
It was particularly disturbing to find underlying evidence that racial, language and cultural tensions were factors in the accident at Rochford. Safety relies on mutual respect within teams, for each other and for each person's role. If this is lacking for any reason, then as well as creating a culture of disrespect, it creates an environment in which accidents are more likely to happen. I am pleased that Network Rail has already recognised this problem in one of its subsidiary companies and is taking action to improve the situation.
Notes
- The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.
- RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.
