A fundamental lack of understanding about crucial paperwork also contributed to the fatal incident at Margam on 3rd July 2019.
The Rail Accident Investigation Branch (RAIB) has released its interim report into the Margam collision.
At around 09:52 hrs on Wednesday 3td July 2019, two track workers were struck and fatally injured by a passenger train at Margam East Junction on the South Wales Main Line. A third track worker came very close to being struck, the report says.
It says: “These three workers, who were part of a group of six staff, were carrying out maintenance work on 9577B points. The driver had made an emergency application of the train’s brakes about nine seconds before the accident and the train was travelling at about 50 mph (80 km/h) when it struck the track workers.
“The RAIB’s preliminary conclusion is that the accident occurred because the three track workers were working on a line that was open to traffic, without the presence of formally appointed lookouts to warn them of approaching trains. All three workers were almost certainly wearing ear defenders, because one of them was using a noisy power tool, and all had become focused with the task they were undertaking. None of them was aware that a train was approaching them until it was too late to move to a position of safety.
“Working on an open line without a formally appointed lookout meant that no single individual stood apart from the work activity at the points with the sole responsibility of providing a warning when trains approached. The absence of a lookout with no involvement in the work activity removed a vital safety barrier.”
The RAIB also reveals that there were paperwork issues.
“The planning paperwork for the work on 9577B points indicated that the work was to start at 12:30 hrs, to coincide with the planned blockage of the up main line. However, witness evidence suggests that there was a widespread belief at the local maintenance depot that there was no need to wait for the planned line blockage in the afternoon, and a general lack of understanding as to how the planning paperwork should be interpreted.
“The system of work that the controller of site safety (COSS) had proposed to implement before the work began was not adopted, and the alternative arrangements became progressively less safe as the work proceeded that morning. These factors had created conditions that made an accident much more likely.”
The investigation is continuing but the RAIB interim report describes the findings and conclusions so far, and outlines the areas for further investigation.
These include: the factors and group dynamics that influenced the actions of the track workers involved; the planning of the work and the interpretation of planning paperwork; the working practices at Port Talbot depot; how compliance with track safety rules was monitored; the selection, training and assessment of track workers, particularly those with responsibility for leading groups; and organisational culture and its impact on safety behaviours.
RAIB will also be carrying out tests to establish the audibility of the various warnings given immediately prior to the accident.
The full report, Track workers struck by a train at Margam, South Wales 3 July 2019, is at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/850403/IR012019_191205_Margam.pdf