The Rail Accident Investigation Branch has now
published its Bulletin on this incident,
on their website:
Learning points
42 The RAIB▸ has decided not to conduct a full investigation as it does not believe that an investigation would identify new safety learning. However, the accident illustrates the importance of applying existing safety knowledge, particularly the learning points given below:
a) Network Rail and other organisations engaged in activities involving work on the railway are advised, as part of their routine briefings, to remind their staff that:
- railway staff working on or near the line must focus on the task in hand and not be distracted by other thoughts or use of a mobile phone. If any staff feel that they cannot concentrate on this task, they must move to a position of safety and tell the person in charge that they cannot do the job safely and ask to be relieved; and
- when acting as a COSS, even when instructing an experienced co-worker, a full briefing must be given to everyone to give assurance that people are aware of the safe system of work and have fully engaged with implementing it; and
- while on or near the line, track workers must acknowledge any warning given by an approaching train so that the driver is better able to judge
whether there is a need to sound an additional urgent warning.
b) Train operating companies are advised, as part of their routine briefings, to remind all drivers that:
- when sounding warnings to people on or near the line, they should pay particular attention to lookouts and other staff who may be remote from a
main group; warnings should start with a blast on the high and the low tone horn (in the loud setting where soft or loud settings are provided), followed by short sharp blasts where no acknowledgement is received or the track worker remains in a dangerous position; and
- train drivers approaching track workers in areas of curved track should appreciate that it can be difficult to see whether these people are in a position of safety until they are close to the individual concerned. If there is any doubt a warning should be sounded.
c) Train operators should endeavour to improve the availability and quality of forward and rear facing closed circuit television recordings because this assists in the evidence gathering needed for safety learning.