SAFETY ALERT NRX22-01 – LOOKOUT OPERATED WARNING SYSTEM INCIDENT
OVERVIEW
At 10:08 on Monday 28 February 2022 the driver of 1Y18 reported a near miss with track workers on the up fast line at Sharnbrook The group of five track workers were regulating ballast using a lookout operated warning system (LOWS).
The LOWS controller received a warning which he cancelled in error.
Immediately after the cancellation another warning was received.
The LOWS controller contacted the lookout for the down lines to thank him for re-applying the warning, wrongly assuming that lookout had also applied the cancelled warning.
In fact, the first (cancelled) warning had come from the lookout on the up lines.
The controller did not positively confirm the down warning was a re-application.
The train travelling on the down fast passed the team who were all in a position of safety and awaiting instruction for work to recommence.
The LOWS controller cancelled the warning still thinking this was the only train in the area and the team resumed work.
The train on the up line (for which the earlier LOWS warning had been cancelled) then approached the site around a curve.
The LOWS controller saw the train and shouted to the team to stand clear.
The team of workers moved to safety on both sides of the track.
The driver sounded the horn but didn’t apply the emergency brake as he could see the team had moved clear.
The train driver came to stop to report to the signaller.
This account from witnesses has yet to be verified from the LOWS data logger.
DISCUSSION POINTS
Responsible managers, Safe Work Pack (SWP) planners and line managers should take the following action:
- Review all human lookout work and ensure it is planned using the hierarchy in NR/L2/OHS/019.
- Work using a human lookout warning should only take place if the task is time critical and cannot be re-planned into better warning or protection systems.
- Every task using unassisted lookouts or LOWS must be specifically authorised by a Director, and only be permitted if alternatives are not possible.
- Wherever there is doubt about warnings, everyone should be stood down in a position of safety and clear communications carried out to confirm understanding.
- Drug and alcohol screening should be carried out with all relevant people in such incidents.
