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

[Meerkat]

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.

The discipline angle doesn’t fully work when the culture is to get the work done. The managers up the chain tick their boxes to cover their arses and know they won’t get disciplined because their superiors are complicit. Regulation of the culture is difficult because it tends to lead to more tick lists and paperwork.
If the individuals are held responsible by the regulator then they have a real motivation to do things properly and to refuse to cut corners, and their managers are under the same pressure.
Everybody in the chain needs to do it right or lose their industry tickets, with less hiding behind the company.

 

[Robertj21a]

The discipline angle doesn’t fully work when the culture is to get the work done. The managers up the chain tick their boxes to cover their arses and know they won’t get disciplined because their superiors are complicit. Regulation of the culture is difficult because it tends to lead to more tick lists and paperwork.
If the individuals are held responsible by the regulator then they have a real motivation to do things properly and to refuse to cut corners, and their managers are under the same pressure.
Everybody in the chain needs to do it right or lose their industry tickets, with less hiding behind the company.

It just sounds like everyone is happy to go along with practices which are blatantly dangerous. That's no way to run a safety critical operation. Hopefully, some heads will roll.

 

[PG]

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.

Symptomatic of too much paperwork which is mainly there as an arse cover.
The correct level of paperwork to do the job safely and properly would lead to folk respecting it as it would have an obvious reason for existing.

 

[Elecman]

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.

Not true ive reported contract staff on the railway infrastructure for safety violations and I know they have had thier Sentinel Cards permanently suspended so they can’t work any more working on NR infrastructure

 

[Spartacus]

It just sounds like everyone is happen to go along with practices which are blatantly dangerous. That's no way to run a safety critical operation. Hopefully, some heads will roll.

Trouble is that, as has been the case here, those with a more senior position in the team on the ground, and more looked up to, sometimes still have a 'back in BR days....' attitude, and that tends to disseminate down to become almost standard practice within the team. "How's it dangerous? We all lived!", ignores all the deaths and injuries there used to be, like a gambler who ignores the losses to focus on the wins, in some ways it's human nature.

A lot of potential incidents are now stopped due to signallers stopping work being done due to incorrect paperwork which could put people in danger, but if they don't inform the signaller.....

 

[alxndr]

Not necessarily related directly to what happened here, but I feel that one of the big issues is the lack of flexibility in the planning system. It generally takes a couple of days to get a line blockage planned (although there is still provision for an unplanned line blockage to be taken under fault conditions). If everything does as planned this isn't an issue, they know what work is coming up and can plan accordingly. The problem is that if work is cancelled for any reason (emergencies, people realising it's not safe, etc) it becomes very difficult to catch up, and there ends up being pressure to "just do it."

The system needs a complete overhaul. Not a kneejerk reaction, tweak or another form, but beginning again completely from scratch. Begin with talking to the people on the ground about why they might do things that aren't entirely safe, anonymously if necessary to get honest answers, and begin from there. I'm a firm believer that there's a reason behind every action. No one wants to put themselves or others in danger, so why did they do something that was unsafe that day? Why did no one feel able to say "hang on a minute, this isn't right"? Or if they did, why did no one listen?

 

[steverailer]

Is some of this down to the public's need for 24 hour travel?

Possessions seem to be getting shorter and more costly, so more work is undertaken under red zone. Luckily, the section of the industry I'm in works very rarely under Red zone (after all we need the juice off to work on the wires) mostly we work red zone on walk outs assessing future works.

I honestly cannot see that the introduction of the Safe work leader system has improved safety one bit over the old system, its just added confusion.

 

[alxndr]

Is some of this down to the public's need for 24 hour travel?

Possessions seem to be getting shorter and more costly, so more work is undertaken under red zone. Luckily, the section of the industry I'm in works very rarely under Red zone (after all we need the juice off to work on the wires) mostly we work red zone on walk outs assessing future works.

I honestly cannot see that the introduction of the Safe work leader system has improved safety one bit over the old system, its just added confusion.

Red Zone isn't inherently dangerous if implemented correctly, Green Zone isn't always safe as things can go wrong.

Safe work leader was never adopted by the majority, instead there's a new "Person in Charge" role which actually makes it less clear who's in charge IMO.

 

[Robertj21a]

Is some of this down to the public's need for 24 hour travel?

Possessions seem to be getting shorter and more costly, so more work is undertaken under red zone. Luckily, the section of the industry I'm in works very rarely under Red zone (after all we need the juice off to work on the wires) mostly we work red zone on walk outs assessing future works.

I honestly cannot see that the introduction of the Safe work leader system has improved safety one bit over the old system, its just added confusion.

Not sure why the public's need for 24 hour travel has much to do with it. Either the line is open for trains - or it isn't. It couldn't get much clearer !!

 

[steverailer]

Red Zone isn't inherently dangerous if implemented correctly, Green Zone isn't always safe as things can go wrong.

Safe work leader was never adopted by the majority, instead there's a new "Person in Charge" role which actually makes it less clear who's in charge IMO.

The 'Person in Charge' role is another none job and doesn't add anything to either the safety or completion of the work. Safe work leader was not adopted by NWR, but most of the contractor jobs are.

Regards red and green, as I say I haven't done much Red (probably 5 shifts over 8 years on the rails), and when I have its been done correctly, and I agree green can be just as bad. But the lack of possession time and cost of getting it pushes jobs that should be done under green onto red.

Not sure why the public's need for 24 hour travel has much to do with it. Either the line is open for trains - or it isn't. It couldn't get much clearer !!

Why not? The public moan when lines are closed for maintenance and they can't get to where they want to be (just look at any bank holiday or the upcoming Xmas blockades). Certain areas you can only get a few hours on a Saturday night to get in and do anything. Surely this leads to some work pushed onto red zone working as getting a possession would be disruptive and costly?

The way I read the report (I'm not a track worker so am free to be corrected), the job they were doing was general maintenance not fault repair. Yes the IBJ the others were looking at was for a fault, but to me why were general maintenance planned that way? As I say I'm only a linesman who's not involved in planning, I just go out and do as I'm asked on my shifts, and am lucky that its mostly green zone (some ALO too so they can get the possession and keep a service running)

 

[w0033944]

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.

There is a history of similar staggering failures of the imagination - the Hixon Disaster of 1968 is the example that comes to my mind.

 

[Robertj21a]

The 'Person in Charge' role is another none job and doesn't add anything to either the safety or completion of the work. Safe work leader was not adopted by NWR, but most of the contractor jobs are.

Regards red and green, as I say I haven't done much Red (probably 5 shifts over 8 years on the rails), and when I have its been done correctly, and I agree green can be just as bad. But the lack of possession time and cost of getting it pushes jobs that should be done under green onto red.



Why not? The public moan when lines are closed for maintenance and they can't get to where they want to be (just look at any bank holiday or the upcoming Xmas blockades). Certain areas you can only get a few hours on a Saturday night to get in and do anything. Surely this leads to some work pushed onto red zone working as getting a possession would be disruptive and costly?

The way I read the report (I'm not a track worker so am free to be corrected), the job they were doing was general maintenance not fault repair. Yes the IBJ the others were looking at was for a fault, but to me why were general maintenance planned that way? As I say I'm only a linesman who's not involved in planning, I just go out and do as I'm asked on my shifts, and am lucky that its mostly green zone (some ALO too so they can get the possession and keep a service running)

It's nothing really to do with the public demand. It's for the railway management to determine if it is safe to run, or not.

Rail staff and the Unions are quick to refer to the need for everything to always be done according to the rule book - but then fail to follow the rules.

 

[Railman]

You would expect things would change after 2 deaths but I would not be too sure 2 is enough to "rock the boat" in NR. Now there was a piece about this report in one newspaper last week, stating the families involved have started legal proceedings against NR, now that might do the trick. NR has had many attempts at track worker safety, BUT none have come to anything practical despite many millions being spent, they are usually thought up by people who dont work "on track" and get too advanced to be stopped because managers must be seen to be "on board" to every crazy initiative or else. The Margam deaths happened in a "system" that was last tampered with when the previous CEO was in charge and they named a HST power car after him.

 

[muz379]

Rail staff and the Unions are quick to refer to the need for everything to always be done according to the rule book - but then fail to follow the rules.

Think its fair to say its only some rail staff who are quick to refer to the need to follow the rules whilst themselves failing to follow the rules . You get that with almost every job surely ? With A number of people working together doing the same role there are statistically going to be some who dont adhere to the rules for various reasons , accidents even fatal ones happen in other industries. And non fatal accidents in jobs without that as a risk happen all the time as well . The job of the investigation now is to find out how and why and if necessary make recommendation to prevent reoccurrence .

Not really sure where you see the union as fitting in with all of this . Ive personally never seen or experienced myself any rail union advocating not following rules . In fact the exact opposite , all of the reps I have ever spoken with have driven home the importance of doing things as per rulebook/agreement/handbook etc . In fact what I have seen in the past is even reps struggling to get people to do things by the book and undermining the unions position on something as well .

 

[Nicholas Lewis]

muz379 yes the RAIB investigations needs to be concluded quickly and recommendations made. However, its noteworthy that RAIB raised considerable concerns in there 2019 annual report https://assets.publishing.service.g...attachment_data/file/798651/AR2018_190430.pdf about the failure of Duty Holders (NR) to adequately implement recommendations made in there previous investigations and its noteworthy that they cite no less than eight from previous track worker investigations they have concerns with. I would suggest several of them will have a read across to this terrible tragedy (see P15). Also ORRs annual report https://orr.gov.uk/__data/assets/pdf_file/0019/41419/annual-health-and-safety-report-2018-19.pdf raised concern about track worker safety and identifies actions that are needed to secure improvements (P18). Both reports predate this tragedy but sadly foretold the residual risks that exist for track workers. Lets hope this will be now be the time to take a fresh approach to understand why the safe systems of working get eroded by those its supposed to serve rather than just introduce more paperwork.

 

[45107]

Not really sure where you see the union as fitting in with all of this . Ive personally never seen or experienced myself any rail union advocating not following rules . In fact the exact opposite , all of the reps I have ever spoken with have driven home the importance of doing things as per rulebook/agreement/handbook etc . In fact what I have seen in the past is even reps struggling to get people to do things by the book and undermining the unions position on something as well .

Without wishing to be confrontational, I suggest you study Robertj21a previous posts in other threads regarding unions.
My interpretation is that it is anti-Union but I would welcome evidence to prove me wrong

 

[Robertj21a]

Without wishing to be confrontational, I suggest you study Robertj21a previous posts in other threads regarding unions.
My interpretation is that it is anti-Union but I would welcome evidence to prove me wrong

Unbelievable.......

This sorry episode is nothing whatsoever to do with me 'bashing' Unions (usually just the RMT, and for good reason) and if you read what I wrote, and took those blinkers off, you might better understand.

My point is, quite simply, that all rail staff and unions are, rightly, very keen to highlight the generally excellent safety record on the railways, over many years. They have always emphasised that strict compliance with the Rule Book is what has enabled that situation to arise. Then we have a situation like this terribly sad event where people have been killed, seemingly because the Rule Book was not followed - and yet various posters on here are suggesting that it's not unusual for the strict procedures to be ignored, and management do not discipline those involved. If management are not doing their job properly what are the staff, and relevant union, doing to safeguard their members lives ?

 

[43096]

You would expect things would change after 2 deaths but I would not be too sure 2 is enough to "rock the boat" in NR. Now there was a piece about this report in one newspaper last week, stating the families involved have started legal proceedings against NR, now that might do the trick. NR has had many attempts at track worker safety, BUT none have come to anything practical despite many millions being spent, they are usually thought up by people who dont work "on track" and get too advanced to be stopped because managers must be seen to be "on board" to every crazy initiative or else. The Margam deaths happened in a "system" that was last tampered with when the previous CEO was in charge and they named a HST power car after him.

So you think it is all down to management and nothing to do with those on the ground following the rules and using some basic common sense. I very much doubt any NR manager is going to advocate the “system” of work used in this case: to be blunt, those directly involved are those primarily to blame.

 

[alxndr]

So you think it is all down to management and nothing to do with those on the ground following the rules and using some basic common sense. I very much doubt any NR manager is going to advocate the “system” of work used in this case: to be blunt, those directly involved are those primarily to blame.

I don't think that's fair to say at all. Ultimately they were the last line of defence against an unsafe occurrence happening, but at the same time none of them would have wanted what happened that day to happen. Either they didn't understand the risk, or they were under so much pressure that they felt as though they had no choice.

While management may not have advocated not having a proper lookout, they do seem to have appeared to advocate splitting into two groups and not having a distant lookout.

 

[43096]

I don't think that's fair to say at all. Ultimately they were the last line of defence against an unsafe occurrence happening, but at the same time none of them would have wanted what happened that day to happen. Either they didn't understand the risk, or they were under so much pressure that they felt as though they had no choice.

While management may not have advocated not having a proper lookout, they do seem to have appeared to advocate splitting into two groups and not having a distant lookout.

Disagree. If you don’t understand the risk of working with ear defenders on, on an open main line, with no lookout, then you shouldn’t be working on the track at all. You’re a danger to yourself and others.

 

[alxndr]

Disagree. If you don’t understand the risk of working with ear defenders on, on an open main line, with no lookout, then you shouldn’t be working on the track at all. You’re a danger to yourself and others.

More likely I think would be misjudging the seriousness of a lookout getting distracted for a moment. That's getting back into the realms of speculation though, and isn't appropriate.

 

[steverailer]

I don't think that's fair to say at all. Ultimately they were the last line of defence against an unsafe occurrence happening, but at the same time none of them would have wanted what happened that day to happen. Either they didn't understand the risk, or they were under so much pressure that they felt as though they had no choice.

While management may not have advocated not having a proper lookout, they do seem to have appeared to advocate splitting into two groups and not having a distant lookout.

Not sure I understand what pressure they may have been under. A safe system was in place for the job to be done, they decided to go against that system and get the work completed early thus bypassing the safe system that was put into place (line blockages in the afternoon). We're not talking green horn, freshly out of blue hats guys here, they were long term railway men. I think that there is a lot more to this than has been released at present regarding the back story as to why the work was done in the morning instead of later as planned.

We recently had a safety stand down where this was discussed, and everyone on there said they would have challenged it due to not working as planned. Now its easy to say that in a stand down where you're mind is focused, and I know of 2 who were there who wouldn't and haven't challenged things in the past but moaned about it after. I have challenged and refused to work in the past and will do in the future if I believe something is wrong. And every stand down we have comes back to the same root cause to most of these, complacency.

Especially in the current lack of work climate, the problem is made worse as guys don't want to rock the boat for fear of losing the little work they are getting. I can't see that this was a problem at Margam due to them being all NWR employees, but zero hours contracts has put some guys on edge to what they say/do. The whole industry needs to look at sorting the issues out rather than focusing on easy targets like gloves and glasses and lack of sponsor names on PPE.

 

[45107]

Unbelievable.......

This sorry episode is nothing whatsoever to do with me 'bashing' Unions (usually just the RMT, and for good reason) and if you read what I wrote, and took those blinkers off, you might better understand.

My point is, quite simply, that all rail staff and unions are, rightly, very keen to highlight the generally excellent safety record on the railways, over many years. They have always emphasised that strict compliance with the Rule Book is what has enabled that situation to arise. Then we have a situation like this terribly sad event where people have been killed, seemingly because the Rule Book was not followed - and yet various posters on here are suggesting that it's not unusual for the strict procedures to be ignored, and management do not discipline those involved. If management are not doing their job properly what are the staff, and relevant union, doing to safeguard their members lives ?

There are 3 parties involved in the process. You are targeting the staff and the union. Management have a big role to play and if their view is ‘get the job done’, staff will and do cut corners to complete it. A sad fact of life.

 

[alxndr]

Not sure I understand what pressure they may have been under.

You are fortunate in your working environment and team then. There can be pressure not to get work done, even if not as dire as that of a contractor who needs to put food on the table. You might be right and that might not have anything to do with it, but it does happen.

A safe system was in place for the job to be done, they decided to go against that system and get the work completed early thus bypassing the safe system that was put into place (line blockages in the afternoon).

That was what was planned, but the report also says that there was a lack of understanding about what safe system they were supposed to be using. That's a major issue.

We're not talking green horn, freshly out of blue hats guys here, they were long term railway men. I think that there is a lot more to this than has been released at present regarding the back story as to why the work was done in the morning instead of later as planned.

Agreed.

We recently had a safety stand down where this was discussed, and everyone on there said they would have challenged it due to not working as planned. Now its easy to say that in a stand down where you're mind is focused, and I know of 2 who were there who wouldn't and haven't challenged things in the past but moaned about it after. I have challenged and refused to work in the past and will do in the future if I believe something is wrong. And every stand down we have comes back to the same root cause to most of these, complacency.

I agree that complacency did probably play a big part, but there will be other factors in play too. For something to go that wrong there will have been a series of events. No one thing will be the cause.

I think the reality is that if you're in moment quite a few more wouldn't say anything. Maybe they wouldn't realise what was going on, maybe they wouldn't want to rock the boat if else seemed happy with it, maybe they wouldn't be sure if it was wrong, or maybe they'd think they'd get away with it. And for as long as people make the right noises in standdown briefs nothing will change.

Especially in the current lack of work climate, the problem is made worse as guys don't want to rock the boat for fear of losing the little work they are getting. I can't see that this was a problem at Margam due to them being all NWR employees, but zero hours contracts has put some guys on edge to what they say/do. The whole industry needs to look at sorting the issues out rather than focusing on easy targets like gloves and glasses and lack of sponsor names on PPE.

Already touched on the first point, that I disagree with, but wholeheartedly agree on the latter.

 

[option]

How would a lookout communicate with those people that have got ear defenders on?

 

[Nicholas Lewis]

How would a lookout communicate with those people that have got ear defenders on?

Touch lookout should have been method of warning with the COSS briefing it to the group before commencing work

 

[ainsworth74]

You would expect things would change after 2 deaths but I would not be too sure 2 is enough to "rock the boat" in NR.

It isn't just two deaths though. Another bloke was killed on the track near Purley in 2018. In October 2017 we had a gang of track workers nearly wiped out by a train on the ECML in Nottinghamshire. In January 2019 a group of workers were nearly killed when they set up their work site south of Durham when it was supposed to be north of Newcastle. And I'm sure there are others out there of a similar nature. It doesn't take things playing out slightly differently and we could have had a lot more people killed on the track than the too many that we've already had.

The cold reality, to my mind, is that there is something wrong either in Network Rail or in their contractors or both.

 

[Robertj21a]

There are 3 parties involved in the process. You are targeting the staff and the union. Management have a big role to play and if their view is ‘get the job done’, staff will and do cut corners to complete it. A sad fact of life.

I'm not sure which one of us can't read English.

Nowhere have I been targeting the staff and the union - unless you're deliberately trying to misread what I wrote. I stated '......management do not discipline those involved'. Immediately followed by 'If management are not doing their job properly what are the staff, and relevant union, doing to safeguard their members lives'.

Others would suggest that I'm 'bashing the management' !! - my whole point being that management does not appear to be doing the key job they are employed to do - manage.

If you still believe that to be some attack on rail staff, or any union, then I despair for you.

 

[Class 170101]

Is some of this down to the public's need for 24 hour travel?

Back in history of course some routes did have some sort of 24hr operation it seems.

 

[Class 170101]

The cold reality, to my mind, is that there is something wrong either in Network Rail or in their contractors or both.

Sadly this wouldn't surprise me one bit.