RAIB Safety Digest: Track workers in near miss on WCML between Carlisle and Lockerbie

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ainsworth74

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The RAIB have published a safety digest on this incident from November 2019 where a group of track workers had to jump clear of a Virgin Trains service approaching at 125mph with less than a second to spare:

At around 09:00 hrs on Thursday 14 November, three members of Network Rail staff had to jump clear of a train travelling at a speed of 125 mph (200 km/h) near Kirtlebridge, Dumfries and Galloway. The staff had just begun a track inspection under the protection of the radio-based Lookout Operated Warning System (LOWS) when the train approached unexpectedly round a bend. The train driver sounded the horn and applied the emergency brake. The staff jumped clear less than one second before the train passed. There were no injuries.

The LOWS equipment they were using at the site of work comprised a receiver unit equipped with flashing lights and a siren intended to warn staff working nearby when a train is approaching. The lights and siren start operating when switches are operated on one or more transmitter units connected to the receiver unit by a secure radio link. A person designated as the LOWS controller remains with the receiver unit while each transmitter unit is operated by a LOWS lookout. The controller and each lookout carry a dedicated mobile phone, provided with the LOWS equipment, to communicate while using the equipment. LOWS is regularly used on the West Coast Main Line in southern Scotland because the combination of high train speeds and curved track often precludes use of a warning system relying on lookouts using flags.

The incident occurred at Merkland, 3.2 km south of Kirtlebridge emergency crossovers, while staff were inspecting the track. The site team comprised nine members of Network Rail staff including a Controller of Site Safety (COSS), LOWS controller and two LOWS lookouts. The system of work required one of the LOWS lookouts to be positioned 1.8 km north of the site of work and the other to be positioned 2.5 km south of the site. The LOWS team were all experienced users of this equipment and had worked in this area on many previous occasions.

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Link

Drilling into it it appears that the lookout to the north and the LOWS controller did not come to a clear understanding:

There is conflicting evidence about the words spoken during the conversation at 08:58 hrs during which lookout (north) and the controller reached a different understanding about whether the lookout duties had already commenced. The controller stated he said “right, that’s you up and running”. The lookout states the controller told him he was going to phone the other lookout and thought the controller was then going to phone him back.

Witness evidence shows that members of the LOWS team were following their normal practice of using informal language, rather than the formal communication protocol mandated by Network Rail. It is certain that their conversation did not result in a clear understanding between the staff involved and it is likely that use of the formal words “you are now looking out” would have resulted in lookout (north) appreciating that the LOWS controller was expecting him to be sending warnings when the incident occurred.

The lookout also stated that he would normally start sending warnings after the system was tested and without a further phone conversation. This is the process described in the LOWS training but, on this occasion, he left the conversation thinking he would be called back.

So we have another incident where only good luck and quick reactions prevented a horrible accident with a number of track workers killed following on from the horrific accident in South Wales and other near misses around the country. This one also comes with a flavour of incident at Balham (which occurred before this in April 2019 and had a report published in February 2020) where safety critical communication was not up to standard and contributed to a serious near miss.
 
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pdeaves

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So we have another incident where only good luck and quick reactions prevented a horrible accident with a number of track workers killed following on from the horrific accident in South Wales and other near misses around the country. This one also comes with a flavour of incident at Balham (which occurred before this in April 2019 and had a report published in February 2020) where safety critical communication was not up to standard and contributed to a serious near miss.
I wonder if talking to mates in the regular team is a problem. By that, I mean it might engender more formal communications if the team was different every time (so it doesn't become 'I know what Bob meant when he said X because that's what he always means' and one time he doesn't mean that). Rostering practicalities may prevent this in every occasion, of course.
 

BRblue

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I wonder if talking to mates in the regular team is a problem. By that, I mean it might engender more formal communications if the team was different every time (so it doesn't become 'I know what Bob meant when he said X because that's what he always means' and one time he doesn't mean that). Rostering practicalities may prevent this in every occasion, of course.
This is actually a very good point and one which had not occured to me before... familiarity breeds contempt is a saying that IMHO could be appropriate here.
 

GRALISTAIR

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I wonder if talking to mates in the regular team is a problem. By that, I mean it might engender more formal communications if the team was different every time (so it doesn't become 'I know what Bob meant when he said X because that's what he always means' and one time he doesn't mean that). Rostering practicalities may prevent this in every occasion, of course.
Definitely an excellent point.
 

Lucan

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I don't know the details of the LOWS, but would have thought that the lookout's transmitter unit should have a LED or small flag indicator on it to show when the system had gone live, set that way by a radio signal from the controller's receiver unit. In other words, all the while the lookout's handset was showing a "Live" indication, he should give a signal if a train is approaching. That would be in addition to the voice communication.

I once rigged up a similar system for a series of on-board train tests (to protect equipment, not life) and it did save a potentially expensive foul-up on one occasion, when voice contact was lost.

I guess that if the LOWS radio connection between the transmitter and receiver units is lost, the receiver unit defaults to warning mode.
 

RichT54

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I wonder if it would be of benefit if all the radio communications could be recorded, so that staff would know that it could be reviewed which may be an incentive to use the correct procedures?
 

43096

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I wonder if talking to mates in the regular team is a problem. By that, I mean it might engender more formal communications if the team was different every time (so it doesn't become 'I know what Bob meant when he said X because that's what he always means' and one time he doesn't mean that). Rostering practicalities may prevent this in every occasion, of course.
Given the number of fatal incidents and near misses there have been with track workers in recent times, you would think that would shake people out of their complacency and sloppiness. Evidently not.
 

Jimmy Foster

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This does sound like real sloppiness and someone clearly didn't do what they should have - the team got so, so lucky. You don't hear too much about people being sacked by Network Rail for safety related failure these days, I wonder what happened with this one. I don't advocate more sackings but maybe the complacency is linked to the chance of being sacked more than to the chance of causing an accident.
 

edwin_m

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I don't know, but if you were the lookout and a train came thundering past you, wouldn't you just operate the LOWS warning system anyway...?
That could cause problems if the other lookout, who according to the description operated the same set of lights and siren, was checking their equipment at the same time.
 

greatkingrat

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That could cause problems if the other lookout, who according to the description operated the same set of lights and siren, was checking their equipment at the same time.

So what would happen if trains were coming from both directions? If there is only one set of lights, is there a danger the workers could go back on the track after the first train passes and get hit by the second train?
 

edwin_m

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So what would happen if trains were coming from both directions? If there is only one set of lights, is there a danger the workers could go back on the track after the first train passes and get hit by the second train?
I guess there must be some extra indication that is checked before the workers are allowed to go back, but I can't say for certain.
 

Trackman

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So what would happen if trains were coming from both directions? If there is only one set of lights, is there a danger the workers could go back on the track after the first train passes and get hit by the second train?
There's a display on the control/warning unit telling you which lookout unit has sent a warning.
 

mbonwick

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I don't know, but if you were the lookout and a train came thundering past you, wouldn't you just operate the LOWS warning system anyway...?
It does say that that the lookout normally would do that...
The lookout also stated that he would normally start sending warnings after the system was tested and without a further phone conversation. This is the process described in the LOWS training but, on this occasion, he left the conversation thinking he would be called back.

It's not beyond the bounds of possibility that the tone of the controller/word choice gave the implied impression that there was an issue with the other lookout that needed fixing...in that situation I could see it being very counter productive to have 1 lookout 'working' while trying to get the other up & working.
 

Re 4/4

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in that situation I could see it being very counter productive to have 1 lookout 'working' while trying to get the other up & working.
Agreed, but I'd have thought the fail-safe way of communicating would be that the lookout warns from the initial call onwards unless explicitly told to hold off until further instructions. Possibly with that instruction being repeated back to the controller to confirm.

Implied impressions don't work in safety critical calls, for obvious reasons.
 

O L Leigh

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It's not beyond the bounds of possibility that the tone of the controller/word choice gave the implied impression that there was an issue with the other lookout that needed fixing...in that situation I could see it being very counter productive to have 1 lookout 'working' while trying to get the other up & working.

I’m not sure that I’m inclined to agree. There’s no doubt that the comms standards were low, but if someone said to me “right, that’s you up and running” I don’t think I’d be waiting for another call from the COSS. Yes it’s possible that there may have been issues with the south lookout, but these could only have been in the mind of the north lookout as otherwise I wouldn’t imagine that the crew would have been allowed to start work. Had the north lookout operated the LOWS as he should, no confusion would have been caused.
 

mbonwick

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There’s no doubt that the comms standards were low, but if someone said to me “right, that’s you up and running” I don’t think I’d be waiting for another call from the COSS.
I agree, but only if that was the exact phrase used. If it was something like right, that’s you up and running, but I need to wait and phone (south)” I can certainly see how you'd possibly form the impression to wait for further instructions.
Unfortunately we don't know the exact phrasing that was used, so there's no way of objectively deciding what was actually said. All we do know if comms protocols were well below standard and the two people in the conversation came away with two completely different understandings.

Agreed, but I'd have thought the fail-safe way of communicating would be that the lookout warns from the initial call onwards unless explicitly told to hold off until further instructions. Possibly with that instruction being repeated back to the controller to confirm.

Implied impressions don't work in safety critical calls, for obvious reasons.
Precisely how it should work!
 

O L Leigh

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I agree, but only if that was the exact phrase used. If it was something like right, that’s you up and running, but I need to wait and phone (south)” I can certainly see how you'd possibly form the impression to wait for further instructions.
Unfortunately we don't know the exact phrasing that was used, so there's no way of objectively deciding what was actually said. All we do know if comms protocols were well below standard and the two people in the conversation came away with two completely different understandings.

Quite. But that’s how it’s been presented in the RAIB digest so far. We shall only know for sure once the investigation is complete.
 

mbonwick

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Quite. But that’s how it’s been presented in the RAIB digest so far. We shall only know for sure once the investigation is complete.
We will never know for sure as
1. the conversation took place over mobile phone, for which there are no recordings (so the only people who know exactly what was said are the COSS and lookout) and
2. this safety digest is the conclusion of the RAIBs investigation - there is no further full report to be published.
 

bishdunster

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Allegedly, a quote from a Railway Inspectorate investigation many years ago. "And the two men concerned came to a clear misunderstanding" o_O.
 

island

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I don't know, but if you were the lookout and a train came thundering past you, wouldn't you just operate the LOWS warning system anyway...?
Perhaps. But the train came seven seconds after he’d finished a call, the conclusion from which was that he was going to wait for further instruction.
 

O L Leigh

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We will never know for sure as … this safety digest is the conclusion of the RAIBs investigation - there is no further full report to be published.

My bad. I'd got it in my head that it was an interim report.

Perhaps. But the train came seven seconds after he’d finished a call, the conclusion from which was that he was going to wait for further instruction.

Not so. The train reached the north lookout 7 seconds after the call to the south lookout was completed but over 2 minutes since the north lookout had completed his call to the COSS.

Quite why he reached that conclusion will remain a mystery, but clearly he was the only person in that group who thought this. Quite why an experienced lookout who is used to using LOWS would do this is strange, especially as he would normally start sending warnings straight away. The RAIB clearly finger poor comms, and I'm sure that's correct and the learning point they'd all like us to take away this incident. I just find it more interesting than that and am wondering what other human factors might have been at work that caused him to diverge from his normal mode of working.

Informal language was clearly the modus operandi for this group so, while the rail industry cannot condone it's use from a safety standpoint, it would not necessarily be considered unusual practice and therefore unlikely to cause confusion. It may have been that he'd gone back to his procedures and got himself muddled as to which protocol he was meant to be following; whether it was the SMF/SE/0338 protocol that requires two phone conversations between the COSS and each lookout or the updated training for a simplified protocol they'd all be trained on after receiving upgraded LOWS equipment. Although the RAIB does not consider this a factor in this incident (no doubt lead by the witness testimony following the event), the digest does comment on this in section 3 and gives another plausible explanation as to why the lookout may have expected a second call from the COSS. The problem is, as has been outlined, that no-one will ever know for sure.
 

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Are track workers given a print out of train times for the section where they are working to give them an idea when a train is due?
 

pdeaves

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Are track workers given a print out of train times for the section where they are working to give them an idea when a train is due?
No, you never, ever, ever rely on a timetable when working on track (what if it's late or early or an additional non-planned working?).
 

John B

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Thanks for reply although I didn't mean for the timetable to be gospel, just additional information giving the normal frequency expected but always expect the unexpected.
 

alxndr

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Thanks for reply although I didn't mean for the timetable to be gospel, just additional information giving the normal frequency expected but always expect the unexpected.

Absolutely not. People would start to rely on it, whether consciously or subconsciously, and accidents would happen. You never know what changes are going to be made and people tend to take things written down as gospel (see also social media).

Incidents have happened where lookouts have "learned" that the trains in that area normally follow a regular pattern of up direction, down direction, up direction, etc which worked fine until the trains stopped following that pattern and they missed one because they thought the next train wouldn't approach from that direction. The last thing you want is to encourage people to try to predict train movements.
 

Elecman

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Absolutely not. People would start to rely on it, whether consciously or subconsciously, and accidents would happen. You never know what changes are going to be made and people tend to take things written down as gospel (see also social media).

Incidents have happened where lookouts have "learned" that the trains in that area normally follow a regular pattern of up direction, down direction, up direction, etc which worked fine until the trains stopped following that pattern and they missed one because they thought the next train wouldn't approach from that direction. The last thing you want is to encourage people to try to predict train movements.
Indeed see Staplehurst !!
 

edwin_m

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Indeed see Staplehurst !!
For those that don't know, back in Victorian times they were replacing part of the track between each train, working by the timetable, but the person in charge forgot about, or mis-calculated, the boat train whose timetable varied with the state of the tide. One of the passengers was Charles Dickens and although he survived he was never quite the same again.

The timetable will be used, indirectly, in planning possessions so as not to interfere with the train service unless unavoidable. But even if the plan says a possession can start at a particular time it doesn't unless the signaller gives permission, as for example there might be late-running trains still to pass through.
 
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