Fatal accident to track workers at Margam last year - RAIB report today

[martin_wynne]

RAIB has today published its report into the tragic accident at Margam last year.

 

Press Release: https://www.gov.uk/raib-reports/report-11-2020-track-workers-struck-by-a-train-at-margam

 

Report: https://assets.publishing.service.gov.uk/media/5fabd9c9e90e075c4965171e/R112020_201112_Margam.pdf

 

[Oldddudders]

A depressing read, not just because people died, but because paper processes seem to count for very little at working level - are we surprised? - so the whole safety edifice seems fatally flawed. The most bitter irony is that the guys who died were doing a job that wasn't actually necessary. 

[simontaylor484]

A dreadful waste of life and trauma to those affected. 

It seems to be a case of we do it like that because we have always done it like that. 

 

[TheSignalEngineer]

On 12/11/2020 at 19:28, Oldddudders said:

A depressing read, not just because people died, but because paper processes seem to count for very little at working level - are we surprised? - so the whole safety edifice seems fatally flawed. The most bitter irony is that the guys who died were doing a job that wasn't actually necessary. 

Any incident resulting in serious injury or death is still deeply felt across much of the railway 'Family' From reading the details of what happened it seems to me that things have gone backwards in the time since I left the industry although we were far from perfect in those days. There seems to have been a total lack of checking how the job was being done in favour of ensuring that there was someone's signature in every box on the paperwork even if it was the wrong person.

 

[Poor Old Bruce]

On 12/11/2020 at 20:32, simontaylor484 said:

It seems to be a case of we do it like that because we have always done it like that. 

 

That is not the case. In BR days, staff working with noisy equipment would have had a 'touch lookout' whose sole job it was to watch for approaching trains and physically prod the worker he was protecting to warn them to stand clear. Where more than one man was using a noisy bit of kit, they may have needed a touch lookout each if there was a significant distance between them. When working on a 'live' track, the Lookout would be the first man out onto the track and the last man off.

[iands]

44 minutes ago, Poor Old Bruce said:

 

That is not the case. In BR days, staff working with noisy equipment would have had a 'touch lookout' whose sole job it was to watch for approaching trains and physically prod the worker he was protecting to warn them to stand clear. Where more than one man was using a noisy bit of kit, they may have needed a touch lookout each if there was a significant distance between them. When working on a 'live' track, the Lookout would be the first man out onto the track and the last man off.

On some types of equipment (Kango hammers etc.) there were also 'cut-out' buttons in the power lead. These buttons were held 'depressed' by the site Look Out. When a train was seen approaching the work site, the Look Out would 'release' the button cutting out the power to the equipment being used. This was the cue for the 'operator' to stand clear because a train was approaching. Didn't matter that he would be wearing ear defenders, no power, tools don't work, step back to place of safety. Not sure if such systems are still widely used, but would seem not in this very tragic case. 

[keefer]

On 12/11/2020 at 20:32, simontaylor484 said:

It seems to be a case of we do it like that because we have always done it like that. 

And this seemed to apply all the way up the ladder to management level.

The adjustments and maintenance being undertaken were common practice with older S&C made up from individual components - but no-one seemed to be aware that the newer designs of S&C were not to be maintained like this. They were set at the factory then installed as a complete unit with no need for component maintenance like this.

I think the report mentions that even if adjustment was necessary, it should've been with a torque wrench and not a powered impact wrench.

Irrespective of this, it's very sad and tragic that even workers with so much experience can be distracted from the task, however briefly, at just the wrong moment.

[martin_wynne]

Ear defenders could be fitted with a bleeper, operated by the lookout. Fail-safe to bleep if the connection from the lookout is broken.

 

[Oldddudders]

In the wake of Clapham, where the trivial cutting of corners by an over-worked new-works technician killed a lot of people, safety and 'quality' became the watchwords. The need to measure quality was met by widespread implementation of BS5750/ISO9001 principles, with a Director, Organising For Quality being appointed at Board level, and a whole industry of safety and quality management being created within BR. Form filling, so producing auditable trails, was new and sexy. As we have seen in this tragic case, it tends to be trusted because it suits everyone for it to be so.

 

To my mind, safety systems should start at the lowest level - where the risk is! - and then feed upwards. Thus safe-working methods are agreed and understood by the chaps at coal-face level - because they devised them. Top-downing a paper trail has been shown yet again to be meaningless. 

[TheSignalEngineer]

3 hours ago, martin_wynne said:

Ear defenders could be fitted with a bleeper, operated by the lookout. Fail-safe to bleep if the connection from the lookout is broken.

 

We used a bleep system operated by the advance lookout but not in ear defenders. There was a second lookout stationed with the team to ensure the warning was heeded.

To be fail-safe the lookout held the handset button pressed to operate the bleep. He released the handset when a train was approaching. No bleep meant keep clear of the track until the person in charge said it was safe to do so.

We also had a similar fixed system operated by train movements in a particularly noisy spot at Willesden. 

[TheSignalEngineer]

3 hours ago, Oldddudders said:

To my mind, safety systems should start at the lowest level - where the risk is! - and then feed upwards. Thus safe-working methods are agreed and understood by the chaps at coal-face level - because they devised them. Top-downing a paper trail has been shown yet again to be meaningless. 

Our depots had Safety Reps elected by the staff. When I was in charge I would meet with them on a monthly basis to brief any forthcoming changes, review any accident reports and duscuss problems raised by site staff. On top of this they could request a special meeting with me if an urgent issue arose.

During the aftermath of Clapham and the S&T fatalities at Edge Hill we reviewed the working methods on all of our projects from the necessity  to work on live railway and equipment right down to how kit was safely stowed in the van. All were done in conjunction with the staff reps and I arranged for them to have open forums with the men to discuss how things were done with management staff only involved for the round-up session at the end of the day.

Edited November 15, 2020 by TheSignalEngineer