Railway worker fatally struck by train at Purley (06/11)

[Randomer]

The report makes very sad reading my sympathies go to the families of those involved.

The Chief Inspector certainly doesn't mince his words on this. Frankly it's one of the most strongly worded comments I have seen from the RAIB even the old HMRI reports that brought about major changes (in law in some cases) were not as strongly worded as this.

I would be very curious how any railway employer going forward could suitably assess the fatigue risk of employees on zero hours contracts when the law states that such contracts cannot be exclusive or prevent people from taking up other work?

There is no indication of that in the report; he hadn't been working particularly long hours in the previous couple of days, but had little sleep and had spent the day decorating at a friend's house.

Four and a half hours in the previous twenty four does seem like an incredibly low number. From personal experience I would struggle to perform the safety critical parts of my (non railway) job with that little rest.

 

[PG]

Firstly my heartfelt condolences to all who were involved in this tragic incident.

The ORR (Office of Rail and Road) don't exactly come out of this smelling of roses.
More than one instance of Network Rail saying that a previous RAIB recommendation has been/will be met/investigated/considered and the ORR not checking that this is indeed the case or that the response is satisfactory.
I have to call into question the fitness for purpose of the ORR as it appears to be an exercise in rubber stamping/box ticking.

I'm interested in the views of drivers and track workers in respect of the use/effectiveness of possession limit boards and detonators, as parts of the RAIB report seem to suggest that the benefits that they provide as a last-line-of-defence are outweighed by the risks to those placing and removing them. Those individuals are indeed at risk but the protection provided to many others may well justify that risk?

 

[itomx]

The incident is truly sad and tragic as well as the report that details the causes. My thoughts are with the family and train driver. It just goes to show that there need to be more rigorous protection and safety procedures in place

 

[jagardner1984]

A terrible incident, you really can't imagine the pain the family is going through ....

Things will only really change when the people start to challenge the parameters of short term, insecure, zero hours, "self employed" or contract work. I imagine there are many other examples of road vehicles being driven by fatigued people causing road accidents. The "flexibility" such work offers seems almost always to benefit the employer but actively disbenefit the employee. Technology should offer us much better ways of recording the working patterns and rates of pay of all workers. Some might say such technology is resisted because it would reveal uncomfortable truths about the rate of pay of our Amazon delivery driver, or the shift patterns our zero hours contract track workers are forced to undertake.

It is heartbreaking that anyone should lose their life at work, particularly in these circumstances.

Society should have stronger mechanisms to give hard working people a good standard of living without excessive working.

 

[LAX54]

From https://www.gov.uk/government/news/report-072019-fatal-accident-at-stoats-nest-junction-purley :

Spoiler: Summary of the Incident:

At around 00:28 hrs on the morning of 6 November 2018, a passenger train from London Victoria to Three Bridges, travelling at about 69 mph (111 km/h), struck and fatally injured a track worker in the vicinity of Stoats Nest Junction, near Purley. The accident occurred after the track worker had placed equipment on the track as part of the arrangements for the protection of an engineering possession. Having placed the protection equipment, the track worker then walked along the track until he reached the end of the protected area, and continued walking with his back to rail traffic on an open line. He may have been going to look at some lineside equipment, and believed that no trains would approach on the line he was walking along. He was probably fatigued, and may have been distracted by personal issues linked to the fact that a second person, the possession support assistant who was supposed to be with the track worker, was not present as he had not attended for work that night.

Underlying factors associated with the accident were the nature of the work which exposed the track worker to risk while he was putting out protection for the possession; that the labour supplier’s management processes had not sufficiently identified and addressed the risk of fatigue among zero hours contracted staff; and that the labour supplier’s management processes had neither identified nor prevented staff absenting themselves from work without being detected.

Spoiler: Recommendations:

The RAIB has made two recommendations and identified three learning points. One recommendation is addressed to Network Rail, to improve the way its labour suppliers manage the risks associated with the use of workers on zero hours contracts, in particular the management of their lifestyle and fatigue. The second recommendation is addressed to Vital Human Resources Ltd, the labour supplier, to commission an independent review of the actions it has taken following the accident at Stoats Nest Junction to assess their effectiveness in detecting and preventing the type of behaviour seen in the accident, and reduce the risks from fatigue. The RAIB has previously made recommendations about reducing the exposure of staff to risk while carrying out possession protection duties, and these are still being considered by the railway industry.

A learning point highlights the need for safety-critical staff to be aware that distraction caused by family issues or other employment may affect their fitness for duty. Other learning points highlight the importance of track workers being alert to the risks on the railway, even when they believe that they are working under protection, and the limitations of the railway industry’s ‘Sentinel’ system if it is used for establishing the presence of staff on site.

Simon French, Chief Inspector of Rail Accidents said:
This sad accident was the first in more than four years involving the death of a track worker who was struck by a train.

When workers are employed on a casual basis on zero hours contracts, there can be great pressure for them to try and juggle multiple jobs to make ends meet. The possible effects of such patterns of employment on fatigue and fitness for work are significant. We are therefore recommending that the railway industry reviews the way it manages the use of staff on zero hours contracts, to minimise the risk associated with this pattern of work.

The continuing requirement for people to go onto the track to place and remove red lamps and explosive detonators, as part of the arrangements for protecting engineering work on the railway, is something that RAIB has queried before. Following a fatality at Reading in 2007, and again after a near-miss in north London in 2017, we recommended that the railway industry should find ways of eliminating the need for people to be exposed to the risk of being struck by trains in these circumstances.

Modern technology means that there are many ways in which the position of trains can be established, and warnings given to drivers and to track workers, if a train movement goes beyond a safe limit. I believe that the industry should continue to explore ways of eliminating the need for Victorian methods of protection on the twenty-first century railway. It is deeply saddening that another person has died while putting down protection for his fellow railway workers- there must be a better way.

The need to better manage the continuing risk to those who work on the tracks has again been highlighted by the tragic death of two track workers who were struck and killed by a train at Margam, near Port Talbot, on 3 July. RAIB has started a detailed investigation into the causes of this dreadful event. This will clearly identify the lessons to be learnt and any necessary recommendations for the improvement of safety.

My thoughts are with all those affected by both these tragic accidents.

It truly is awful reading about this kind of topic.

Dets can still be a safe last resort protection for a possession, 3 big bangs under your feet, will alert you ! In our area, when staff need to place the dets out, they take a line block to protect themselves to and from the detonator location. Network Rail a few years ago wished to dispense with dets on blocks, but the Unions fought a hard battle to keep them, there needs to be stricter 'supervision of contract companies that bid for the work, new ones seem to pop up weekly !

 

[Ducatist4]

One thing that I recall reading in another accident report is that the train driver sounded a series of short horn blasts to warn someone on the track in front of him rather than a single long one which could be mistaken for an acknowledgement that they’d been seen by the driver rather than a warning to get out of the way if that makes sense.
I’m in no way trying to blame the driver in this case but I was surprised it wasn’t mentioned in this report.

 

[Tomnick]

One thing that I recall reading in another accident report is that the train driver sounded a series of short horn blasts to warn someone on the track in front of him rather than a single long one which could be mistaken for an acknowledgement that they’d been seen by the driver rather than a warning to get out of the way if that makes sense.
I’m in no way trying to blame the driver in this case but I was surprised it wasn’t mentioned in this report.

A series of short high-tone blasts is given in the rule book (TW1, 45.2-45.3) as the way to sound an urgent warning to someone in a dangerous position.

 

[TheEdge]

The Chief Inspector certainly doesn't mince his words on this. Frankly it's one of the most strongly worded comments I have seen from the RAIB even the old HMRI reports that brought about major changes (in law in some cases) were not as strongly worded as this.

Can we get a paragraph reference for that? No one comes out of this particularly well, or do you mean the whole report in general?

 

[theking]

Deleted

 

[4069]

Can we get a paragraph reference for that? No one comes out of this particularly well, or do you mean the whole report in general?

It's in the press release accompanying the report, https://www.gov.uk/government/news/report-072019-fatal-accident-at-stoats-nest-junction-purley . Scroll down to the bottom.

 

[AlterEgo]

I usually read RAIB reports with an air of dispassionate misery but this one has made me really angry.

The actions given for NR to improve upon are long overdue. Zero hours workers have their place in modern society but should not be undertaking safety critical tasks. It's likely the COSS was walking in the four foot instead of the cess because he was simply tired and not thinking straight. The PSA - had he been present - would have had the duty of observing him place the protection and return to a place of safety. Had the PSA been there, the accident would have been very unlikely to happen.

Nonetheless, where they do, the employees have a fundamental duty of care to themselves and one another. Reading about "ghosting", which is, in plain English, a fraud where you say you're at work but actually in bed, and claiming pay for it, made me want to punch a window out. Had the PSA been present with the COSS it's likely one or other would have realised the risks, completed the work safely and and walked in the damn cess instead of in the four foot.

No amount of equivocation is permissible where a factor in a fatal accident happening is down to individual staff members perpetrating a fraud.

A total disgrace. Utter disgrace.

 

[whhistle]

Hope you read the whole thing, about how the guy was on zero hours contract and had to find other work to make a living.

Hope you read the bit about how the guy was having to work as a delivery driver during the day, no doubt on another zero hour contract.

Hope you understand the stress the guy who was killed was under , because he was trying to help out his brother...

I understand and not trying to change your point of view but personal life choices / situations should not become a higher priority than carrying out work properly (IE, to approved procedures).

Nobody forced the person to take a second job, nor help his brother painting.
There are plenty of places to get help if you have a low wage but it's about understanding how the person came to be in that situation that is important.

The COSS did not follow procedure and ultimately paid for it with his life.

 

[TheEdge]

Yep, you can almost sense the angry typing from the Chief Investigator there.

I must say I'm pretty shocked the railway uses zero hours agency contracts in safety critical rolls. Maybe I'm just exceedingly naive but that just seems like an appalling idea from the get go.

 

[pacenotes]

Most construction jobs are contract. ie job to job which would come under a zero hour contract.

 

[LowLevel]

What a sad read. As a direct railway employee I had no idea such practices were present.

 

[Bromley boy]

A series of short high-tone blasts is given in the rule book (TW1, 45.2-45.3) as the way to sound an urgent warning to someone in a dangerous position.

Indeed. Not sure it would have made a difference in this case, sadly, but it’s as well to be reminded of the rules.

On a related note, on my patch (which isn’t so very far away from where this sad incident occurred), there is a tendency for drivers not to blow up when p-way are observed in and around possessions, especially late at night, on the basis that “it’s ok, they’re in a possession”.

I know it wasn’t a particular factor in this incident, but it’s still a good reminder of how easily complacency can set in.

Much better to always err on the side of caution. Even if it’s 0100. Even if it might annoy people.

 

[alxndr]

A series of short high-tone blasts is given in the rule book (TW1, 45.2-45.3) as the way to sound an urgent warning to someone in a dangerous position.

True, but I think it's understandable that the driver might not have acted this out to the letter when realising that the COSS was in his path and just five seconds away. I can imagine the human instinct would just be to blast the horn and slam the brake in. I'm amazed that someone wouldn't react with urgency to a five second blast on a horn, that would be far longer than a typical blow up and something he would be bound to be familiar with as a driver of a road vehicle as a warning/someone isn't happy. That either demonstrates just how sure in his own mind the COSS was that they were safe and/or how distracted they were.

In addition to the recommendations already given in the report, I can't help but wonder if there would be any merit in investigating the general state of walking routes and cesses. The COSS was in the habit of walking in the four foot and did so despite training and there being "a safe, reasonably even walking route" available (para. 73) so you have to ask why he had developed the habit. If good walking routes were more widely available the four foot may never have become his default.

 

[Antman]

I read it and it looks like a pretty carefully written report, with a deliberate attempt to be gentle to the person who didn't come to work. You see it all the time with coroners inquests. They are desperate not to upset families and the conclusions are often 'nowhere near the truth'. But it's better to not make it even worse for them.

I read it and have my own thoughts as to the controls, work practices and enforcement, versus the lack of visibility on costs at the contractor to whom they were supplied. and no doubt the agency kept quiet as it collected a healthy commission and had access to a flexible workforce. As well as to NR who are ultimately paying for it. I suspect this is part of the problem with the railways working at night. They tend to cut corners. And I would suspect that it is rife. It's just that it fortunately so rarely has such drastic consequences.

 

[Bromley boy]

I read it and have my own thoughts as to the controls, work practices and enforcement, versus the lack of visibility on costs at the contractor to whom they were supplied. and no doubt the agency kept quiet as it collected a healthy commission and had access to a flexible workforce.

Not to condone the sharp practices outlined in the report, but if workers are engaged through agencies on zero hours contracts, presumably for low pay, they won’t exactly be invested in their jobs, or be inclined to take them seriously (who can blame them?!).

As has been noted above, safety critical tasks should not be performed by those employed on these terms - have we learned nothing from Potters Bar, the Hidden Report etc.? It’s not just their own safety these guys are responsible for, it’s that of the general public.

As well as to NR who are ultimately paying for it. I suspect this is part of the problem with the railways working at night. They tend to cut corners. And I would suspect that it is rife. It's just that it fortunately so rarely has such drastic consequences

Not sure working at night is a particular factor (lots of inspections and other work is undertaken during the day when lines are open for traffic), it’s more a function of having a remote, disparate workforce.

 

[ainsworth74]

I must admit I've been thinking for a little while now after the various reports and bulletins that came out of the string of near misses we've had of late that Network Rail rely on contractors far more than they should for stuff which should be done in house by staff directly employed by Network Rail. Fair enough for huge projects like the Waterloo remodelling or the upcoming Kings Cross throat works there is a role for contractors to provide the additional manpower and resource for those large scale projects. But other stuff? The more nitty gritty day to day maintenance work? That should surely sit wholly within Network Rail? Why are Network Rail using a bunch of contract staff (also on zero hours contracts) to go trackside to do some minor maintenance in between trains on the ECML for example (Egmanton level crossing incident)?Same goes for the provision of COSS's, PICOPs, lookouts, etc. Those are all roles that are so important to the safety of everyone on a work site that they should be in-house roles for Network Rail to deliver on all occasions.

 

[Elecman]

I must admit I've been thinking for a little while now after the various reports and bulletins that came out of the string of near misses we've had of late that Network Rail rely on contractors far more than they should for stuff which should be done in house by staff directly employed by Network Rail. Fair enough for huge projects like the Waterloo remodelling or the upcoming Kings Cross throat works there is a role for contractors to provide the additional manpower and resource for those large scale projects. But other stuff? The more nitty gritty day to day maintenance work? That should surely sit wholly within Network Rail? Why are Network Rail using a bunch of contract staff (also on zero hours contracts) to go trackside to do some minor maintenance in between trains on the ECML for example (Egmanton level crossing incident)?Same goes for the provision of COSS's, PICOPs, lookouts, etc. Those are all roles that are so important to the safety of everyone on a work site that they should be in-house roles for Network Rail to deliver on all occasions.

A fair bet for a reason being Network Rail having to comply with ORR unrealistic targets for efficiency savings.

 

[YorkshireBear]

Honestly, I found this one of the most anger inducing and thought provoking RAIB reports I have ever read. There is so much to run through.

ainsworth74 you are absolutely spot in in my opinion. Zero hours contracts in a safety critical environment is not in my opinion acceptable. It carries too much risk in safety culture in particular but also then fatigue etc. These jobs are not the sort of jobs we should be accepting zero hours. And you cannot take people on zero hours and tell them they can't take other jobs on.

The only other thing for now is the lack of PSA did not directly cause the issue, a PSA is not actually needed around the country and is only needed in 3rd rail areas. So the PSA wouldn't be there in possessions on the ECMl for example. The fact that it annoyed him he hadn't showed up was a casual factor in his state of mind and concentration but no a direct attribution.

Plenty more to comment on but work to do!

 

[island]

This was a hard report to read.

I agree with the other observations that using zero hours workers in safety critical roles is something that should be avoided.

Practicing a fraud upon the company may or may not have contributed to the incident; the report also mentioned that the brother was in the habit of walking in the four foot as well so they might have just both done it and both ended up the same way.

 

[Plethora]

I deal with insurance PI claims, and have come across a few on the railway. I don't have a comprehensive insight, but my thoughts are as follow:

The underlying issue is that NR is incentivised to outsource work in order to reduce staffing liabilities, but this is done in an environment where contractors seem to be chosen primarily on price (Admittedly this is nothing novel).

Beyond this however, I remember having a discussion with a contractor H&S officer on a claim who told me that they accepted they used unsafe working practices (it concerned an overly manual method of removing pandrol clips), but that their methods were constrained by the specification set out by NR. In my case there was equipment that could have avoided the injury, but which was not sanctioned by NR. Under clause 2.2 of the CAHA however they retained the liabilities for the injury. My understanding is all contractors have to sign up to this before they can even bid for work.

This leads to a perverse situation as contractors may have to accept certain liabilities as part of the cost of doing business. The effect of such a situation is that insurance premiums are likely to spiral after a couple of years, and in such a context it is not surprising that contractors adopt a "here today gone tomorrow" approach, which feeds into their approach to H&S. Furthermore we know that business ethos is as important as anything in creating an environment in which accidents are avoided, and this will usually start at the top. If a director knows their business won't be around for long, that will be felt throughout the company.

I do feel that the effect of these factors in the long term are producing a less safe working environment on the railways. Unfortunately I don't see anything changing. It suits the government to outsource risk to the private sector.

 

[Tomnick]

True, but I think it's understandable that the driver might not have acted this out to the letter when realising that the COSS was in his path and just five seconds away. I can imagine the human instinct would just be to blast the horn and slam the brake in. I'm amazed that someone wouldn't react with urgency to a five second blast on a horn, that would be far longer than a typical blow up and something he would be bound to be familiar with as a driver of a road vehicle as a warning/someone isn't happy. That either demonstrates just how sure in his own mind the COSS was that they were safe and/or how distracted they were.

Indeed, there's absolutely no criticism of the driver's actions intended. As the report highlights, it can be difficult to establish whether someone is really in a position of safety when they're on the other side of a complex layout to you - you do really have to trust their judgement in acknowledging your warning. A long blast on the low tone has always struck me as more likely to draw attention than a series of short blasts on an often squeaky high tone! I'm sure there's some science behind the rules though.

Indeed. Not sure it would have made a difference in this case, sadly, but it’s as well to be reminded of the rules.

On a related note, on my patch (which isn’t so very far away from where this sad incident occurred), there is a tendency for drivers not to blow up when p-way are observed in and around possessions, especially late at night, on the basis that “it’s ok, they’re in a possession”.

I know it wasn’t a particular factor in this incident, but it’s still a good reminder of how easily complacency can set in.

Much better to always err on the side of caution. Even if it’s 0100. Even if it might annoy people.

Agreed, a complacency that seems increasingly common on both sides - I've noticed more and more staff on or about the line who don't bother acknowledging, which is tolerable when they're clearly well away from the line in question but still gives the driver the responsibility of satisfying himself that they appear to be in a position of safety. Not directly relevant here, but perhaps indicative of a slip in standards generally.

 

[2HAP]

Tbh, I'm really trying hard right now to moderate what I really want to say to you......

Hope you read the whole thing, about how the guy was on zero hours contract and had to find other work to make a living.

Hope you read the bit about how the guy was having to work as a delivery driver during the day, no doubt on another zero hour contract.

Hope you understand the stress the guy who was killed was under , because he was trying to help out his brother...

Try walking in the shoes of others and come down from the pedestal you've put yourself on.

The report is a tragic realisation of modern day working practices for many, and no people wonder why the unions decide to defend jobs with decent working conditions....

Yes, I read the whole report. I wouldn't have commented otherwise. I've had experience of a zero hours contract, and the abuses that can come of being employed on one, such as falling out with a supervisor and then not being offered future work. It still does not give anyone free reign to perpetuate a fraud on their employer.

 

[Randomer]

Can we get a paragraph reference for that? No one comes out of this particularly well, or do you mean the whole report in general?

My apologies as another poster has pointed out the comments by the Chief Inspector don't actually form a part of the text of the report.

The two parts that really stood out for me were:

When workers are employed on a casual basis on zero hours contracts, there can be great pressure for them to try and juggle multiple jobs to make ends meet. The possible effects of such patterns of employment on fatigue and fitness for work are significant....

I believe that the industry should continue to explore ways of eliminating the need for Victorian methods of protection on the twenty-first century railway. It is deeply saddening that another person has died while putting down protection for his fellow railway workers- there must be a better way.

Taken from here:
https://www.gov.uk/government/news/report-072019-fatal-accident-at-stoats-nest-junction-purley

 

[notlob.divad]

The only other thing for now is the lack of PSA did not directly cause the issue, a PSA is not actually needed around the country and is only needed in 3rd rail areas. So the PSA wouldn't be there in possessions on the ECMl for example. The fact that it annoyed him he hadn't showed up was a casual factor in his state of mind and concentration but no a direct attribution.

I wanted to comment on this point.
I have to say as an outsider it both suprises and scares me that anyone is expected to work alone at night anywhere on the rail network.

 

[Ducatist4]

I subscribe to these reports and also to the AAIB ones which come out monthly. They never apportion blame and really just set out the sequence of events in a factual way then make recommendations as to how the same situation could be avoided in the future.
Could there now be a civil or HSE action based on the finding of this report, the same as happened after the Shoreham airshow accident and people could end up going to jail (in theory)?

 

[KingJ]

Regarding the allocation of blame, fault or potential legal action as a result of this report, I would highly recommend that all posters carefully read the preface of the report. Although it is the same standard preface present in all RAIB reports, it clearly sets out the intent and deliberate limitations of this, and all other, RAIB reports. Similar text can be found in AAIB reports. (Of course, in spite of the preface the report may still find usage in situations contrary to the preface, but that is for someone with far more legal expertise to determine the appropriateness of)

Beyond that, I must say that this is the most harrowing RAIB report i've read in a while. I can only hope that substantial lessons are learned from this, especially around zero hours contracts. It is not good enough to point to the rules and say that something is forbidden - people are ultimately influenced by the environment they are placed in and that needs to be recognised. If you put people in an environment where they have no job security, and highly inconsistent income and hours it is not surprising that they will, with good intent, bend the rules to improve those conditions. This is ultimately a systemic failure, and some of the actions reported as being already taken in paragraphs 143 and 144 do not appear to properly address this - treating the symptoms rather than the cause.