SHARED LEARNING – NRL19-06-SUNDON NEAR MISS

At approximately 23:50 hours on Wednesday 12th December 2018, the East Midlands Trains' 1D91 London St Pancras to Derby service approached two isolated staff who were walking back-to-traffic on the Down Fast line.

The train was travelling at 101mph, although the linespeed was 125mph.

The driver of 1D91 sounded a warning horn and applied the emergency brake.

On realizing the imminent danger, one of the staff members pushed the other clear of the Down Fast and into the open Up Fast where he sustained minor injuries due to contact with the running rail.

The two staff did not get to a defined position of safety, but managed to get clear of the path of the train a fraction of a second before the train passed them.

The two workers accessed the open Down Fast line on the misunderstanding that it was the blocked Up Slow line.

The pair had become disorientated, in part due to the safety brief they received being carried out at a different location on the opposite side of the railway to the point that they arrived at to access the track in their vehicles.

There were access points on opposite sides of the railway, linked by a footbridge which contributed to the misunderstanding.

There were no access point information boards at either access point.

Although experienced workers, the two staff had little experience on the section of line concerned.

The work group comprised of an Authorised Person (AP) and an Earthing Assistant.

The AP was also fulfilling the duties of a Controller of Site Safety and Person in Charge (COSS/PIC).

The AP was unclear about the role he was supposed to be carrying out.

The AP did not receive a brief on the arrangements from the Engineering Supervisor (ES).

Instead the ES briefed the Nominated Person, and the Nominated Person onward briefed the information to the AP.

Consequently, the AP/COSS/PIC did not directly speak to the ES and did not sign in with him.

In briefing the AP, the Nominated Person was not filling any official Rule Book role.

When the Nominated Person signed in with the ES, he also signed out to enable him to avoid going back to the ES's location once the work was finished.

The shortcut had become custom and practice.

The AP/COSS's Safe Work Pack (SWP) did not detail the access point arrangements and was provided to him just 10 minutes before the planned start time.

Any person working as a COSS in an engineering worksite should ALWAYS receive a brief from the ES and sign the RT3199.

A COSS MUST NOT sign-out with an ES at the same time he/she signs in, unless the work is cancelled.

Every work group MUST have a SWP and Person in Charge.

Anyone going on or near the line shouldalways be absolutely clear about the access,egress and protection/warning method.

Any COSS or PIC should ALWAYS have the Safe Work Pack to check and understand a minimum of a shift in advance.

Copies of Safety Advice are available on Safety Central