OVERVIEW
On 21 September 2021 at 23:20, four members of staff working on behalf of Route Services crossed the Up and Down Hendon Lines to egress the operational railway at Hendon Station without a Safe System of Work in place despite being aware that the lines were open to traffic.
The Level 2 investigation found that the Person in Charge (PIC) and the Controller of Site Safety (COSS) deliberately broke the Rule Book, Standard NR/L2/OHS/019 (‘Safety of people at work on or near the line’) and the ‘Plans and Permits’ Life Saving Rule.
They chose to rely on personal judgement rather than contacting the Signaller, the Responsible Manager (RM), Route Control, SCO 24/7 or waiting for an imminent possession to be granted and contacting the Person in Charge of the Possession to arrange a method of safe and compliant egress.
The COSS & PIC have each had their COSS competence suspended for a two years.
The underlying causes were identified which placed the team in a position where they had to make unplanned decisions, these are shown below.
UNDERLYING CAUSES
- Egress was planned through an official access point across third-party land without arrangements being made for the PIC to get the key which would have released the team through a locked car park gate.
- Responsibilities were not clear at the planning stage. A separate COSS was appointed on the night of the shift who completed the PIC’s fields in the SWP, while the actual PIC briefed the team on the work and supervised its activities. It was not appropriate to split the PIC role.
- The workload of the Planner and the Responsible Manager led to overreliance on the PIC to plan and manage the delivery of the work.
- Earlier in the shift, at 21:00, there had been a failure by the COSS and the Signaller to reach a clear understanding, vital information was not provided to the Signaller when a line blockage was requested and a line (the Hendon Chord) remained open when the team first crossed the Up and Down Hendon Lines.
KEY MESSAGE
- Standard 019 clearly defines how work must be planned by the RM, Planner, PIC and others who can provide additional technical expertise working together.
- Senior leaders should make sure the RM,Planner and PIC have the right time, training and equipment to comply with Standard 019.
