RAIB Rail Accident Report - Track Worker Struck by Train near Roade, Northamptonshire, 8th April 2020

Our Ref: HSR/2/1
Head Office Circular: NP/236/21
5th July 2021
To: The Secretary
ALL BRANCHES
REGIONAL COUNCILS

Dear Colleague,

RAIB RAIL ACCIDENT REPORT – TRACK WORKER
STRUCK BY TRAIN NEAR ROADE,
NORTHAMPTONSHIRE, 8 APRIL 2020

I have received the final report of the Investigation into the fatality involving an RMT member which was published on 9th June 2021. The report can be viewed here.

RMT had previously commented on the draft report as follows (RAIB’s responses are in italics):

Whereas the RAIB report captured the facts, I need to highlight that there are a lot of comments on the COSS/PIC’s site behaviour not being consistent with the rules. However, what is missing from the RAIB report is that the other site employees may have also been repeatedly ignoring the rules. This includes the long-reach excavator working at the top of the bank ignoring sleepers laid out to stop them driving too near to the edge. On the morning before the fatality the site CCTV shows the long-reach excavator encroaching within 9m prior to the isolation being taken. This seems to be evidence that no one was willing to challenge the site unsafe behaviours/attitude.

The focus of RAIB reports is always on the issues directly causal to the accident and hence why in this case it focusses on the behaviour of the track worker. However, we do make mention to other non-compliant activities, for instance the work at the tow of the slope continuing without the COSS.

A possible explanation or contribution as to why no one offered any challenge is discussed in paragraph 105.

On the day of the fatality the only site COSS/PIC left the worksite to assist the two ISS OHL contractors at the north and south end of the job which was out of sight of the worksite. The site work was not paused and carried on the work without the COSS/PIC which I am informed is quite common practice; no one challenged the unsafe act- this included the managers who created the safe work packs and appointed just one COSS/PIC.

RAIB has reinforced its description of the non-compliant working practices you describe, in paragraph 34.

A possible explanation or contribution as to why no one offered any challenge is discussed in paragraph 105.

The COSS/PIC was, in my mind, set up to fail due to staff shortages on site and poor planning for the 019 standard which is in the RAIB report. The staff shortage could have been a result of the lack of funding due to the AmcoGiffen low tender bid being accepted by Network Rail. The AmcoGiffen bid was half of the nearest bidder, which consisted of five other companies. The AmcoGiffen bid was around £750,000; the next nearest bid was over £1.5 million. It is a known fact that the contracting companies will push the price up once the work starts and that Network Rail keeps extra money aside for these unforeseen anomalies.

Paragraphs 104 and 105 provide a possible explanation as to the cause of the informal behaviour of those on site, including the track worker.

The possible causal link between the low tender price and the inadequate safe system of work has been removed. Additional evidence provided during consultation indicated that it was more likely that the safety arrangements had been left flexible to help maintain progress on the site that was suffering as a result of several unforeseen technical issues causing delay to the project. The evidence is that the inadequate safe system of work was probably the consequence of delays as a result of unforeseen technical difficulties.

The report goes into detail highlighting how the safe work pack did not cover the whole site and the Vortok blue fencing had gaps for the high troughing which went higher due to catch pits. The COSS/PIC used the gaps to walk through to access the track once he had taken a line blockage. There was no site warden considered when the SWP was created who would have warned the COSS/PIC that the lines were open.

The issue that the safe work pack did not cover the whole site has been removed as this was only an issue with the mileage recorded on the cover sheet. This was only ever intended to identify the site of the work. Correct mileages were included within the pack.

The safety fencing was not complete, hence why a separated safe system of work had been documented. The lack of provision of a site warden is noted in paragraph 98.

Network Rail did not go onto the site do their self-assurance safety checks due to staff shortages, which was down to having two of their safety advisors seconded elsewhere. To me this was another failure by Network Rail, who knowingly knew the job was under budget. This site should have been at the top of their radar.

Network Rail’s formal assurance activities, as they relate to the Roade site, are described in paragraphs 87 to 92.

The additional checks by Workforce Health Safety and Environment Advisors are discussed in paragraph 93.

The possible causal link between the low tender price and the inadequate safe system of work has been removed on the basis of additional evidence provided during consultation. See response to your comment 03.

AmcoGiffen failed to pick up the poor behaviours whilst doing their site safety inspection. The poor safe work packs should have been their starting point, then the other site safety concerns which I mention above would have been obvious- but were unfortunately ignored or not identified.

When my representative went to the site, he invoked the Worksafe Procedure as the walkway to site meant one had to walk on troughing lids. Everybody on site seemed to accept that this was the norm.

Noted.

The use of troughing as an access route was known by the RAIB, however was not considered to be causal to the accident. For completeness, reference has been added to paragraph 57.


Your National Executive Committee (NEC), at its meeting on 29th June 2021, noted and adopted the following report from its Health and Safety Sub-committee:

We note the contents and findings of the Rail Accident Report. We are not entirely satisfied with its findings nor the comments received from RAIB in response to RMT’s observations. This NEC supports the following comments from our LUHSR as a pertinent observation: “I believe both companies knew the job was undercut which reflected on the front-line safety. The poor planning and blatant daily rule breaches were not picked up in the site safety inspections (or ignored).”

The General Secretary is instructed to promulgate RMT’s response to the Report, including RAIB’s response to our observations, to members.

Relevant Branches and Regional Councils to be advised.

I am acting in accordance with these instructions.

Please bring the contents of this circular to the attention of relevant members.

Yours sincerely

Michael Lynch
General Secretary