Shared Learning NRL24-01 – Operational Close Call at Crewe Station
OVERVIEW
In the early morning of 2nd June 2023, a work group, working for the Internal Delivery Signalling section of NW&C Capital Delivery, were undertaking works at Crewe Station in the area of the Platform 12 ramp.
The team who had been working in the Crewe station area for most of the week under line blockage, were refused the block that evening due to a T3 possession on the same lines.
The staff started to work separated, but then encroached to a line that was in the worksite under possession where they very quickly realised their error and exited the site, however they were reported to the Operations Delivery Manager (ODM) by the Engineering Supervisor (ES).
It has been established through evidence that the line block was booked and accepted after the possession had been created in Possession Planning System (PPS).
The PPS should have been checked and the clash with the mileages would have been made apparent; this would have highlighted that a possession was already in place (and the teams’ work could have been planned into it).
On site, the Site Warden did not enforce the defined limits as briefed by the Controller of Site Safety (COSS) / Person in Charge (PIC) which allowed the workgroup to stray onto the open line, failing to warn the work group members who strayed beyond the limits of the Safe System of Work (SSoW).
KEY MESSAGE
Senior managers and line managers: Review how your teams are managed in respect of NR/L2/OHS/019
- Do you have right the level of capability, supervision and leadership in your teams?
- What and how often are non-technical skills trained and discussed with your teams?
- 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?
PLANNERS: Have you got the requisite processes in place to cross check your plans to ensure no overlapping? Do you use secondary systems for reference that do not automatically align with your planning tools?
FRONT LINE STAFF: Never allow the implemented SSoW to be compromised for any reason. Where there are changes in circumstances that affect the SSoW, the PIC 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.
SUPPORTIVE ASSURANCE: Review how robust your L1 assurance activities are in relation to application of 019 principles.
