The report makes 11 recommendations to improve safety for rail track workers, including: not to waste time on trackside maintenance work that is not essential to operations.
It is a comprehensive 115-page report. Here is the summary.
At around 09:52 hrs on Wednesday 3 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 three workers, who were part of a group of six staff, were carrying out a maintenance task on a set of points. The driver made an emergency brake application about nine seconds before the accident and continued to sound the train’s horn as it approached the three track workers. The train was travelling at about 50 mph (80 km/h) when it struck the track workers.
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. They were carrying out a maintenance activity which they did not know to be unnecessary. All three workers were almost certainly wearing ear defenders, because one of them was using a noisy power tool, and all had become focused on the task they were undertaking. None of them was aware that the train was approaching until it was too late for them to move to a position of safety. Subsequent acoustic measurements have shown that they would not have been able to hear the train’s warning horn.
The system of work that the controller of site safety 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 and created conditions that made an accident much more likely.
RAIB’s investigation found several factors which led to this situation, relating to the work itself, the way the safe system of work was planned and authorised, the way in which the plan was implemented on site, and the lack of effective challenge by colleagues on site when the safety of the system of work deteriorated.
The investigation also considered why Network Rail had not created the conditions that were needed to achieve a significant and sustained improvement in track worker safety. Four underlying factors were identified:
Over a period of many years, Network Rail had not adequately addressed the protection of track workers from moving trains. The major changes required to fully implement significant changes to the standard governing track worker safety were not effectively implemented across Network Rail’s maintenance organisation.
– Network Rail had focused on technological solutions and new planning processes, but had not adequately taken account of the variety of human and organisational factors that can affect working practices on site.
– Network Rail’s safety management assurance system was not effective in identifying the full extent of procedural non-compliance and unsafe working practices, and did not trigger the management actions needed to address them.
– Although Network Rail had identified the need to take further actions to address track worker safety, these had not led to substantive change prior to the accident at Margam.
RAIB has made 11 recommendations in this report. Nine of these are addressed to Network Rail and cover:
– improving its safe work planning processes and the monitoring and supervision of maintenance staff (three recommendations)
– renewing the focus on developing the safety behaviours of all its front-line track maintenance staff, their supervisors and managers
– establishing an independent expert group to provide continuity of vision, guidance and challenge to its initiatives to improve track worker safety
– improving the safety reporting culture
– improving the assurance processes, the quality of information available to senior management, and processes for assessing the impact of changes to working practices of front-line staff (three recommendations).
A further recommendation is made jointly to Network Rail, in consultation with the Department for Transport, relevant transport authorities, the Office of Rail & Road (ORR) and other railway stakeholders, to investigate ways to optimise the balance between the need to operate train services, and enabling safe track access for routine maintenance tasks.
The final recommendation addresses an observation noted during the investigation and is not related to the cause of the accident. It is addressed to the Rail Delivery Group, in consultation with Network Rail and RSSB, and recommends research into the practicability of enabling train horns to automatically sound when a driver initiates an emergency brake application.
RAIB has also noted two learning points: one reminds staff to only carry out maintenance on insulated rail joints when the relevant line has been closed to traffic, and the other reminds companies to update staff on revised maintenance practices as railway assets are modernised.
According to the chief executive of Eave, which sells high-tech ear defenders, there is another lesson from Margram not articulated by the RAIB – that passive ear defenders may protect hearing but add risk to worker safety, dulling the senses of those who wear them.
Eave’s active ear defenders filter out background noise while enabling colleagues to hear each other talk. With microphones on the outside and inside of the earcups, harmful noise is automatically blocked, while useful noise is amplified, Eave says.
Chief executive David Greenberg said: “The RAIB’s report into the tragic accident at Margam represents yet another missed opportunity to improve the safety of railway workers.
“According to the authors of the report, one of the main causal factors of the accident was that track workers did not hear the train approaching. And why didn’t they hear it? According to the report it was because they were ‘using a noisy machine’ and so were unable to hear the oncoming train’s horn or the shouts of their colleagues. With this frustratingly superficial conclusion, the report moves on - completely failing to call out the role passive ear defenders played in the accident in what is a critical section of the report.
“As Eave has said many times, passive ear defenders are not fit for purpose - they effectively blindfold the ears, dramatically reducing situational awareness, and making workplace accidents much more likely. If the victims of the Margam accident had been issued with active hearing protection with hear-through functionality they would have had a much better chance of hearing the oncoming train’s horn - and the shouts of their colleagues - and clearing the track in time.”
“The RAIB’s report says that Network Rail is already ‘seeking technical advice from RSSB on the appropriateness of hearing protection for track workers’. This is quite simply not good enough. We call on Network Rail to mandate active hearing protection for all of their workforce - without delay. Railway workers should not have to choose between deaf or dead; there is no reason to delay and risk the loss of further lives.”