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Near miss with track workers at Sundon, Bedfordshire, 12 Dec. 2018

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Adlington

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RAIB has published a safety digest on this incident: pfd and html
At around 23:50 hrs on the night of 12 December 2018, two track workers narrowly avoided being struck by an express passenger train that was travelling at about 100 mph (161 km/h) on the Midland Main Line near the village of Sundon, Bedfordshire. The track workers quickly moved clear to avoid being struck, having been alerted to the train’s approach when the driver sounded the warning horn.

The near miss occurred because the track workers were walking along a line open to traffic in the mistaken belief they were on a line which was closed to traffic. This confusion arose because the track workers had unintentionally accessed the railway at the wrong location for the planned work.
Given that the confusion was caused by the workers thinking they were in a location different to the intended one, I find the Network Rail's position deeply worrying:
Access point signage, including the access point name and track layout, has been fitted to some access points. However, Network Rail has stated that it does not intend to do this at all existing access points and, in 2010, informed the Office of Rail and Road (ORR, the safety regulator for Britain’s railways) that:

‘A cost benefit analysis had been carried out. It showed that it was not cost effective to retrofit signs at all access points. However it was considered that it would be cost effective to fit such signs at new build access points’.
 
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Bigfoot

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There was a period around 2 or 3 years ago of the access point signs being installed everywhere on the wessex region. Perhaps their position has changed.
 

DarloRich

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I thought the signs were installed.

As an aside these type of posts get very little interest. Perhaps track workers aren't worthy of discussion.
 

hwl

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There was a period around 2 or 3 years ago of the access point signs being installed everywhere on the wessex region. Perhaps their position has changed.
Agreed signage in recent years has much improved. I suspect a change of attitude under the last CEO?

Western will have been cheap as they didn't used to believe in access points which was discovered during electrification!
 

Adlington

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I thought the signs were installed.
They are. But RAIB recommended the signs provide 'track layout information signage at all railway access points, showing mileages, line names and directions and other key items of local railway information, as appropriate’. That's what was missing at Sundon.
 

hwl

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They are. But RAIB recommended the signs provide 'track layout information signage at all railway access points, showing mileages, line names and directions and other key items of local railway information, as appropriate’. That's what was missing at Sundon.
Is suspect some regions have been better at roll out than others.
 

DarloRich

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But RAIB recommended the signs provide 'track layout information signage at all railway access points, showing mileages, line names and directions and other key items of local railway information, as appropriate’. That's what was missing at Sundon.

Apologies. A poorly worded response. I meant I thought such signs HAD been installed. I was unaware they had not been installed at all locations.
 

Arrpi87

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I thought the signs were installed.

As an aside these type of posts get very little interest. Perhaps track workers aren't worthy of discussion.

Bear in mind when the thread was started, while most people are at work. Might pick up later.
 

jamesst

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Agreed signage in recent years has much improved. I suspect a change of attitude under the last CEO?

Western will have been cheap as they didn't used to believe in access points which was discovered during electrification!

I'm not sure this has been done In the North West area much either?
 

Mag_seven

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As an aside these type of posts get very little interest. Perhaps track workers aren't worthy of discussion.

I do find that statement a little bit baffling in that

1.Someone has taken the time to start a post
2.We have 9 comments already.

Getting back to the matter at hand:

A cost benefit analysis had been carried out. It showed that it was not cost effective to retrofit signs at all access points.

In my new therefore if the access point has no sign it should no longer be regarded as an access point.
 
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Hellzapoppin

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All COSSs should have track locator or where am I apps on their phones. The COSS should have local knowledge as per NR standards. The Safe System of Work packs should be given to the COSS at least a shift before work commences so he/she can check they’re correct and if necessary go to site and familiarise themselves on the area they’ll be working. In addition, the latest standard 019 states that the person doing the work must be involved with the planning from the start so again they should know the area. So if a sign isn’t there then that should make little if any difference.
 

DanDaDriver

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I thought the signs were installed.

As an aside these type of posts get very little interest. Perhaps track workers aren't worthy of discussion.

I guess because it doesn’t look as dramatic as it perhaps was.

As an aside, I wonder what percentage of actual near misses with track workers are reported? I’d be surprised if it was high.
 

ainsworth74

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Given that the confusion was caused by the workers thinking they were in a location different to the intended one, I find the Network Rail's position deeply worrying:

It's also worrying that a little over a month after this incident we had a similar case of track workers being in the wrong place and having a near miss with a train:

At approximately 23:45 hrs on Sunday 20 January 2019, a train operated by Northern encountered two track workers who were walking along the Browney Curve on the East Coast main line, South of Durham. The track workers had just set up a work site and were walking with their equipment to get to their place of work. However, because of an earlier planning mistake which went undetected, trains had not been stopped on the line on which the work site had been established. This occurred because the possession (a part of the railway which is closed to traffic to enable engineering works) did not encompass the location of the work.

Link

In the case I've mentioned the mistake was that the possession was north of Newcastle whilst they had turned up to a location south of Durham!
 

Tom B

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What sort of region do the staff work over? Are they subject to site familiarisation,or do they work over such a large area that this is impractical and, in theory, the job card has all the detail they need?
 

Bald Rick

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As an aside, I wonder what percentage of actual near misses with track workers are reported? I’d be surprised if it was high.

Good question. I suspect rather more now than was the case a few years ago. If a driver reports it, then it is immediately investigated. More rare is a team reporting it themselves, but it does happen.

For drivers reading: if you have a near miss please please please report it ASAP.
 

DanDaDriver

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For drivers reading: if you have a near miss please please please report it ASAP.

It’s a similar thing to reporting signallers (although P-Way operate more “Under the radar,” so to speak).

You really don’t want to get someone in trouble (although sometimes I wonder if that’s reciprocated with signallers ;) ) but at the same time, you don’t want it to be a method of working someone’s adopted that gets someone hurt or worse later on.
 

Bald Rick

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It’s a similar thing to reporting signallers (although P-Way operate more “Under the radar,” so to speak).

You really don’t want to get someone in trouble (although sometimes I wonder if that’s reciprocated with signallers ;) ) but at the same time, you don’t want it to be a method of working someone’s adopted that gets someone hurt or worse later on.

For near misses, don’t worry about getting people into trouble. If someone has set up a system of work in good faith that for whatever reason isn’t up to scratch, they won’t get into trouble, but will be given training and guidance. Similarly if a driver reports something that they feel isn’t safe, but on investigation it is safe, then no one gets in trouble.

If, however, someone trackside sets something up knowingly that isn’t a safe system of work, then they will get into trouble, and quite rightly so. It isn’t just their safety either, but also of the passengers and staff on the train.
 

alxndr

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Signage certainly isn't installed at all access points. I'd hazard a guess that less than half in my area has signage.

I can see that it's no small task to install signage, one access point can have two or three different names depending on who you talk to or which document reference and different documents can give slightly differing lists of access points. That doesn't mean it should be excusable not to recognise this as a serious risk with obvious sets of solutions. When completed it would also have the side effect of making it clear which access points are official.

It might appear a waste of time when considering that regular maintenance staff will know their patch like the back of their hand, but contractors will not. I strongly dislike the fact that it's acceptable to COSS in an unfamiliar area and believe that at the very minimum a daytime site visit with someone who has local knowlege should be mandatory before COSSing in an area. In the day you stand a chance of orientating yourself using the position of the sun, landmarks, structures, or mileposts, but at night when all you can see is a small beam from a head torch or vehicle headlights it's much, much harder.

The industry also needs to move away from relying on postcodes. In built up areas they can be reasonably accurate, but in rural areas they can be considerably off. For example, I was recently provided with a postcode that directed me to the other side of a river and railway line to the location I was intended to get to. What3words is one initiative which seems to be gaining some traction and might be something to seriously consider going forward.

My dream wishlist would be:
  1. Site access signage at all access points
  2. An overhaul of the Hazard Directory, with regular updates
  3. An app containing all access points (ideally tied to the Hazard Directory and made available as a set of satnav POI points)
  4. A move away from using postcodes
  5. A ruling that all COSSes should have some form of local knowledge before COSSing an area
  6. The inclusion of detailed track diagrams and/or satellite images in SSOW packs as standard (in addition to the existing Sectional Appendix extracts)
 
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DelW

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As an aside these type of posts get very little interest. Perhaps track workers aren't worthy of discussion.
That's rather harsh. I know there are a number of rail professionals who post on these forums, but I suspect the majority are enthusiasts who may not feel they can add much to this discussion.

The industry also needs to move away from relying on postcodes. In built up areas they can be accurate, but in rural areas they can be considerably off. For example, I was recently provided with a postcode that directed me to the other side of a river and railway line to the location I was tended to get to. What3words is one initiative which seems to be gaining some traction and might be something to seriously consider going forward.
I'm very surprised that anyone would use postcodes to define access points or work locations either in rural or urban areas. Surely grid references would be far more accurate and reliable, and have the advantage of being readily used on paper maps, as well as being displayed by a handheld GPS to an accuracy within a few metres. If you are in the wrong place they can also show you which direction you need to move in, which postcodes won't.
 

alex17595

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What sort of region do the staff work over? Are they subject to site familiarisation,or do they work over such a large area that this is impractical and, in theory, the job card has all the detail they need?

I have been sent all over the place, the furthest North being Gretna Green to Plymouth in Devon. I have had shift 5 mins from home and it's always awful.
 

Tomnick

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What sort of region do the staff work over? Are they subject to site familiarisation,or do they work over such a large area that this is impractical and, in theory, the job card has all the detail they need?
It was common at Manton to receive a phone call from a relieving driver or COSS or whoever, armed with a postcode which got them into the vicinity (into the village of the same name above the tunnel, I seem to recall) but gave them little chance of finding their way down to the yard and the box, tucked away below.

One of the resident signalmen told me about a phone call that he’d received from (IIRC) a PICOP asking for directions to the box so that he could take his planned possession. No need, came the reply - (paraphrased) “if your knowledge of the patch is insufficient for you to find a significant access point, important junction and signal box, then I’m not comfortable granting you the block”. Quite right too.
 

steverailer

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I'm not a COSS but from my work as a machine op, most COSS's don't have local knowledge, they just rely on the ES briefing and the SSOW pack. Unfortunately this is more the norm than it should be, but is the way the industry has gone with the reliance on agency staff and firms rotating their staff around the jobs. I've been on track for 10 years and the standards have dropped year by year, some of the briefings are a joke (had to tell one recently which line was which and which we were accessing!!) These are reported back to my company and are not used again. Luckily we work the same areas a lot so we have quite a bit of local knowledge ourselves, and keep ourselves safe
 

SilentGrade

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Luckily we work the same areas a lot so we have quite a bit of local knowledge ourselves, and keep ourselves safe

The thing is you shouldn’t have to rely on your local knowledge to keep yourself safe. These sorts of incidents are becoming worryingly regular now and although I know there’s no easy answers I find the response on access point signage disappointing (if not surprising) to say the least. We shouldn’t be putting prices on people’s lives

I know there’s no easy solutions but perhaps something along the lines of a QR code at an access point, which can be read to display the same level of information electronically might be a solution? Anything is better than the almost weekly occurrence of either near miss reports or irregularities I see now. If we’ve decided we’re not going to fund the mass roll out of full access point signage, we need to do something (anything), to keep people safe as clearly ‘relying on local information’ is not working!!
 

Elecman

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I'm not a COSS but from my work as a machine op, most COSS's don't have local knowledge, they just rely on the ES briefing and the SSOW pack. Unfortunately this is more the norm than it should be, but is the way the industry has gone with the reliance on agency staff and firms rotating their staff around the jobs. I've been on track for 10 years and the standards have dropped year by year, some of the briefings are a joke (had to tell one recently which line was which and which we were accessing!!) These are reported back to my company and are not used again. Luckily we work the same areas a lot so we have quite a bit of local knowledge ourselves, and keep ourselves safe

Have You or your firm reported these inadequate COSSs to Network Rail for them to be assessed and thier Sentinel Competencies to be suspended/ revoked as necessary? just because your firm won’t use them again doesn’t mean others wont
 

jayah

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It was common at Manton to receive a phone call from a relieving driver or COSS or whoever, armed with a postcode which got them into the vicinity (into the village of the same name above the tunnel, I seem to recall) but gave them little chance of finding their way down to the yard and the box, tucked away below.

One of the resident signalmen told me about a phone call that he’d received from (IIRC) a PICOP asking for directions to the box so that he could take his planned possession. No need, came the reply - (paraphrased) “if your knowledge of the patch is insufficient for you to find a significant access point, important junction and signal box, then I’m not comfortable granting you the block”. Quite right too.

It seems sensible that anyone out walking the track has or is accompanied by someone with route knowledge.

Signage at many access points would be vandalised within hours and providing it just feels like it would be fuelling a compliance blame game.

You could enter at an access point and walk half a mile to where there are now additional lines and junctions.

Incidents of a similar character include a grinder being incorrectly placed on an open line and struck by a train. You cannot manage risk like that with a sign.
 

infobleep

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Agreed signage in recent years has much improved. I suspect a change of attitude under the last CEO?

Western will have been cheap as they didn't used to believe in access points which was discovered during electrification!
If they didn't believe in access points, how did people reach the track?

Personally I find every access point I've come across, that isn't used by the public, to have signs up. Obviously I've not been to move access points but I can't imagine a I have passed are new. Far from it.
 

jayah

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If they didn't believe in access points, how did people reach the track?

Personally I find every access point I've come across, that isn't used by the public, to have signs up. Obviously I've not been to move access points but I can't imagine a I have passed are new. Far from it.

How long will it be before yet another incident of this nature means RAIB recommend regular audits of access point signage for graffiti?

The root cause is obvious, and it underlines why all drivers and guards expected to go onto the track have route knowledge.

If you are bringing in specialist contractors from far and wide into a live railway environment they need to be properly escorted.
 

alxndr

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It seems sensible that anyone out walking the track has or is accompanied by someone with route knowledge.

I agree that all COSSes should have local knowledge of the area they are setting up safe systems in (although it doesn't need to be route knowledge as intense as that of a driver IMO). I see signage as a supplementary reminder to this, not instead of.

Signage at many access points would be vandalised within hours and providing it just feels like it would be fuelling a compliance blame game.

You could enter at an access point and walk half a mile to where there are now additional lines and junctions.

The main issue appears to be people not knowing which orientation the lines are in/which is up and down. There is an extract of the Sectional Appendix diagrams in the SSOW pack which would show if a junction or additional line was going to appear, but if you've lost your bearings and which is the up and which the down it's not a great deal of help.
 

jayah

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I agree that all COSSes should have local knowledge of the area they are setting up safe systems in (although it doesn't need to be route knowledge as intense as that of a driver IMO). I see signage as a supplementary reminder to this, not instead of.



The main issue appears to be people not knowing which orientation the lines are in/which is up and down. There is an extract of the Sectional Appendix diagrams in the SSOW pack which would show if a junction or additional line was going to appear, but if you've lost your bearings and which is the up and which the down it's not a great deal of help.

In this case it would seem they didn't know where they were and as such they didn't realise they were in the wrong place.

They didn't have their bearings to begin with.
 
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