SHARED LEARNING NRL23-05- NEAR MISS AT PENKRIDGE
OVERVIEW / UNDERLYING CAUSES
On Sunday 10th July 2022, a team of Overhead Line Equipment (OLE) staff were responding to an OLE issue affecting the Down Penkridge Line.
The Person in Charge had agreed a line blockage with the signaller and the team split into 3 groups.
Two OLE technicians were instructed to operate an OLE Switch on the Down Penkridge Line, within the limits of the line blockage.
At 23:54, the signaller contacted the Person in Charge to hand back the line blockage to allow a diesel freight train through the area.
At 23:58, the train driver saw two track workers on the line they were travelling on and sounded the warning horn without having time to apply the emergency brake.
Initially it was reported back by the OLE team the technicians were positioned in the cess, however later onboard footage confirmed they jumped clear of the trains path at the last moment.
The two OLE technicians did not have a Safe System of Work (SSoW) when they left the work group to operate the switch.
The Stafford OLE team perceived that the group were under significant pressure to find the fault given their awareness of financial implications should the line remain closed, in addition to the knock-on effect on other planned work and the potential effect on the team’s reputation.
Level 1 assurance in relation to reactive faultfinding work was not intrusive and therefore is not sufficient to fully assure the workforce are working in accordance with NR/L2/OHS/019/01.
The RAIB report has also been published and is available here.
DISSCUSSION POINTS
Line managers:
Review how your teams are supported in dealing with pressures of operational railway during fault scenarios
- Do you have right level of capability, supervision and leadership in your teams?
- What and how often are Non-technical skills trained and discussed with your teams
Senior managers and line managers:
Discuss how communication impacts safety in;
leadership messages, functional cascades and communication during ongoing incident management. Are you unintentionally creating environments where performance, cost and Safety are competing priorities rather than Safety and performance going hand in hand?
Supportive Assurance:
Review how robust your L1 assurance activities are in relation to application of 019 principles; in particular use of Incident Response Packs.
Front-line staff:
Life Saving Rules save lives –
A valid, implemented safe system of work would have avoided the risk of a fatality in this instance. The person in charge shall not allow the implemented SSoW to be comprised for any reason. Where there are changes in circumstances that affect the SSoW ,the person in charge shall make sure everyone in their workgroup moves to a position of safety, and only then shall they reassess and implement appropriate changes in line with the requirements of 019 and the rulebook.
Personal responsibility
Any incident must always be reported as soon as is safe to do so to Route Control and your management. Compromising the safety of yourself or others is not acceptable, we all have a personal responsibility to ensure incidents are reported.
