Margam rail deaths: 'No safe system' when workers killed

Discussion in 'UK Railway Discussion' started by Edders23, 1 Oct 2019.

  1. Edders23

    Edders23 Member

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    https://www.bbc.co.uk/news/uk-wales-49892460
    So despite the railways being the most safety conscious organisation I know it appears basics were not followed :(

    very sad this was definitely preventable
     
    Last edited by a moderator: 14 Oct 2019
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  3. Spartacus

    Spartacus Established Member

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    Highly misleading headline as there was a safe system in place, it just wasn't followed though.

    I've read the Network Rail report and I can't say there's anything that I didn't really think could have been in there after the initial investigation, although I was surprised, almost shocked, just how much of what could have possibly happened actually had.

    No matter how good your precautions are, they mean nothing if they're not followed.
     
    Last edited: 1 Oct 2019
  4. AndyPJG

    AndyPJG Member

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    Quote from above link:-
     
  5. ArchieWoodbine

    ArchieWoodbine Member

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    For further reading, there’s strong similarities between this and the near-miss at Egmanton in 2017.

    Both resulted from a break down in the safe system of work with critical safety roles being allocated ad-hoc; no clear understanding of responsibilities between staff; working at an unplanned location not (or at least poorly) accounted for in the paperwork.
     
  6. edwin_m

    edwin_m Veteran Member

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    Pretty similar to this one that came out only a few days ago too: https://www.gov.uk/government/news/...h-a-track-worker-near-gatwick-airport-station
     
  7. Dai Corner

    Dai Corner Established Member

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    This report from Rail Engineer has a bit more detail. As far as I know the NR report isn't online.

    https://www.railengineer.co.uk/2019...ls-there-was-no-safe-system-of-work-in-place/

     
  8. Tomos y Tanc

    Tomos y Tanc Member

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    It's not a highly misleading headline. It's an actual quote from the report. Railway Engineer uses the same quote as its headline.
     
  9. Edders23

    Edders23 Member

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    the mods altered my original title for the thread ;)
     
  10. Chris M

    Chris M Member

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    The RAIB have released their interim report today: https://www.gov.uk/government/news/interim-report-012019-track-workers-struck-by-a-train-at-margam
    An extract from the summary:
     
  11. alxndr

    alxndr Member

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    I read the RAIB interim report this afternoon when it came out, still trying to digest it to be honest. Very hard to read, especially alongside the images from the train CCTV, trying to imagine what would have been going through the minds of the other half of the group and the driver at that moment...
     
  12. thejuggler

    thejuggler Member

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    The fact two people died suggests the headline is stating the obvious.
     
  13. IslandDweller

    IslandDweller Member

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    "Highly misleading headline as there was a safe system in place, it just wasn't followed though."
    Nothing misleading about the headline. If you have an operating environment where day-to-day operating practice bears little relation to the written safety procedures / method of work then you emphatically do not have a safe system. Procedures are worthless without a management culture that ensures the operating practice actually matches what the written procedures/rules require.
    The circumstances outlined in the report are just jaw dropping.
     
  14. Spartacus

    Spartacus Established Member

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    Quite, although there’s not really anything there that I didn’t expect, I didn’t expect pretty well everything I expected it could have been to have happened, it’s like watching a safety video where everything’s done wrong. I’m expecting it either to be used in a similar fashion in the future, either officially or through word of mouth.
     
  15. PG

    PG Member

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    Four months after this tragic incident and three track workers narrowly escaped the same fate going by this news item on the RAIB website.

    https://www.gov.uk/government/news/near-miss-with-track-workers-near-kirtlebridge
    The photo is shocking especially considering the reported speed of the train.
    [​IMG]
    I'm thankful that although undoubtedly shocked they got to go home alive.
     
  16. 43096

    43096 Established Member

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    But it’s not really much of a surprise. RAIB reports have been on about track workers for some considerable time yet we keep seeing more similar incidents. This is not just about NR management and culture, the staff keep doing the same things and never seem to learn. I do not believe NR are not briefing the lessons from previous incidents out, so there seems to be a basic lack of comprehension from the staff.
     
  17. edwin_m

    edwin_m Veteran Member

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    From the outside looking in, it seems to me that the root cause is not enough people to do the work that needs doing, so people take shortcuts both with the paperwork and with actual safety on site. The response to an accident is often to introduce more paperwork, which may just make things worse.
     
  18. PG

    PG Member

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    As an outsider I'd concur - time for a complete overhaul of how work is undertaken rather than yet another layer of forms to be produced, verified, checked and signed.

    I have seen, in another industry, how the introduction of theoretically good ideas has led to an increased workload for foot-soldiers. This then spawned preprinted forms (in order to save time) which effectively turned the same good ideas into a form selection process. Instead of actually improving safety it became a paperwork exercise which changed nothing on the ground but fulfilled a tick box higher up in the organisation.
    I fear that NR has done the same.
     
  19. 43096

    43096 Established Member

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    It is that latter point that is key. Too much paperwork means it become a box-ticking exercise rather than making any real contribution to safety.

    I just find it utterly astonishing that three people could stand on an open line, likely wearing ear defenders whilst concentrating on a task, with no lookout and none of them think that might, actually, be rather risky.
     
  20. PG

    PG Member

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    Exactly this, thank you for saying it better than I did.
     
  21. Hellzapoppin

    Hellzapoppin Member

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    I worked a night shift on the day this happened and had a Safety stand down with the 2 gangs I was supervising and although I only had quite sketchy info at that time to work with I got the safety message across that we should all work safe, act safe and think safe. I picked out a few stupid things which I see all too often, one of them being people wandering along trackside whilst texting, checking their social media and watching U tube videos. For that shift it stopped but the following night guess what, the same thing happened with the same people on their phones. As said above you can put into place as many Safe systems and processes as you want but people have to buy in to it. There's no easy answer.
     
  22. PG

    PG Member

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    I know it's easy for me to say but with respect to mobile phones could there be a way to have them left at base or in the van ie not trackside?
    As you say unless people buy in to it things won't change - I'm unsure how anyone can get all involved to buy in to it?
     
  23. Hellzapoppin

    Hellzapoppin Member

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    The rules are quite clear regarding phones and that's unless you need a phone to carry out your duties it gets switched off and not used. How anyone can think they'll be safe walking in the 4ft at night whilst texting is beyond me but people do believe they'll be safe no matter what they're doing and sometimes it ends in tragedy. I can assure you it's hard work supervising people nowadays.
     
  24. PG

    PG Member

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    I am sure that it is and I don't envy your job.
    I wasn't intending any criticism of you and others in your position.
     
  25. Hellzapoppin

    Hellzapoppin Member

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    No offence taken PG.
     
  26. Dai Corner

    Dai Corner Established Member

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    If it's against the rules, do staff get disciplined for it? Do contractors / agency / casual workers lose any future work?
     
  27. Meerkat

    Meerkat Established Member

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    Problem with that is the managers are pressured to get the work done.
    The individuals need to be directly held to account by the regulator.
    I worked in finance so dodgy stuff only cost money not lives but being individually regulated made a big difference. Management would want corners cut but individuals would be concerned that their own head would be on the block and they would be blacklisted out the industry.
    “I am not sure we should do that, can you send me an email instruction” ie ‘you put your name and reputation on that decision’
     
  28. Robertj21a

    Robertj21a Established Member

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    Not sure I agree with that. Performance and discipline is down to the immediate manager, but it sounds like they are trying to avoid responsibility.
    For a safety critical job I can't believe that staff flouting the rules aren't disciplibed.
     
  29. Hellzapoppin

    Hellzapoppin Member

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    Staff do get disciplined, the usual start is a rebrief of the rules which should be enough.
    Safety always comes before performance, usually the most productive way to do a job is also the safest.
    Unfortunately you can't just deny people work as it could be classed as discrimination.
     
  30. Class 170101

    Class 170101 Established Member

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    As an industry is it also not helping with the casualisation of labour? One week on a railway worksite(s), the next on a house construction site, the next building a tower block?

    How long is it going to be before red zone working is banned nationwide simply because the labour force isn't capable in being trained to be railway safe so the only way to solve the issue is to remove the trains and resort to green zone working even for the most basic tasks?

    In addition however as an industry are we not helping ourselves by conducting certain tasks using manual methods when frankly it would be better to take the people away and use trains and non manual methods to carry out such tasks?
     
  31. Tom B

    Tom B Established Member

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    And because everyone then associates the paperwork and processes with arse covering and wasting time, they become blasé to it when it actually needs to be followed.
     

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