The Rail Accident Investigation Branch has published its report1 into a collision between mobile elevating work platforms (MEWPs) that took place in Rochford, Essex on 25th January 2020.
At around 10:57am a MEWP collided with a stationary machine of the same type on which two people were installing overhead line equipment. They both suffered minor injuries; that they were wearing safety harnesses might have saved their lives.
The machine operator in charge of the MEWP had lost focus while driving the machine, and was alerted by other members of staff shouting at him to stop. At that point the machine was travelling too fast to stop before striking the stationary MEWP. The machine operator had driven away from the machine controller, who was responsible for the MEWP’s movements, without permission, and drove the machine at around 10 mph, while using the on-board CCTV screen to view the route ahead. These actions were contrary to the applicable operating rules.
Other causal factors, the investigation found, were ineffective supervision of the machine operator and confusion among staff about who was in charge of the safe movement of on-track plant on the site. Cultural factors on the site led to poor working relationships between machine operators and controllers and an excessive focus on ‘getting the job done’, rather than compliance with rules and operating standards. Network Rail’s assurance processes had not identified these issues.
The investigation identified that there were tensions between full-time employees and agency workers, and a culture of racial prejudice among members of staff at various levels of the workforce towards contractors supplied by labour agencies, including those undertaking the role of machine controller. The investigation concluded that this had had an impact on the safety of the site, and the behaviour and attitudes had affected and undermined the ability of machine controllers to discharge their duties safely.
"There were reportedly racial and cultural tensions between the predominantly white OCR [Overhead Condition Renewals] full-time employees, and predominantly black agency-supplied machine controllers," the report says.
"Some agency machine controllers reported that the attitude towards them and the role they were performing was disrespectful. Several agency workers expressed frustration about the cultural environment, which they said had affected their confidence and their ability do their job properly."
RAIB has made five recommendations, each addressed to Network Rail. The first is to review and clarify the roles and responsibilities of staff working in possessions and work sites to avoid duplication of responsibilities and confusion arising between roles. The second recommendation is that Network Rail should undertake a review of the way that the Sentinel scheme is managed, in respect of incident investigations and how training providers and primary sponsors assess the English language skills of staff who undertake safety critical duties.
The third recommendation is addressed to Network Rail (Anglia), to review its reporting and response process for accidents and incidents, and the fourth recommendation seeks a review of the equipment currently used to alert staff to a dangerous situation within a possession or work site. The fifth recommendation is to commission an independent review of the internal culture and working practices of Network Rail’s Overhead Condition Renewals business unit. The investigation also identified five learning points.
Simon French, chief inspector of rail accidents said: “Although the consequences of this accident were minor, the people who were in the machine that was struck could easily have been killed if they had not been wearing their safety harnesses.
“Our investigation found a catalogue of errors and omissions which could have had much more serious consequences. We found duplicated lines of control, leading to confusion and a lack of clarity about who was in charge of the work and the machinery that was being used. As well as the safety risk this creates, it’s also inefficient and wasteful. Network Rail needs to find a more effective way of managing the movements of multiple vehicles in work sites.
“It was particularly disturbing to find underlying evidence that racial, language and cultural tensions were factors in the accident at Rochford. Safety relies on mutual respect within teams, for each other and for each person’s role. If this is lacking for any reason, then as well as creating a culture of disrespect, it creates an environment in which accidents are more likely to happen. I am pleased that Network Rail has already recognised this problem in one of its subsidiary companies and is taking action to improve the situation.”