Powerpoint presentation given to IOSH Rail Conference on 23/11/10

2. This presentation considers:
• the risk of track workers being struck by
trains
• how well this risk is managed by rules and
other risk controls
• barriers to improvements
and
• suggests where we go from here
It is supported by a conference paper that contains
everything in this presentation

3. RSSB Safety Risk Model
Probability of an individual
track worker being killed by a
train is 1 in 15850
Fatality risk from
all causes is 1 in
9860. Being
struck by a train
accounts for 63%
of this risk

4. 52 Fatalities ‐ 1990 to 2009 (SSoW failure only)
Successful campaign to emphasise rules compliance in early 90s
Is continuing this approach alone sufficient to eliminate fatalities?

5. Analysis by SSoW ‐ 1994 to 2009
• 32% of fatalities are those providing the SSoW
• Lookouts, when used, are 55% of fatalities
• Some SSoW may present intolerable levels of risk
Safe Role
System of Work
Total
COSS/
IWA
Lookout
Protection
Assistant
Machine
Controller
Other
Workforce
Established Possession 5 1 4
Possession Set Up 2 2
Open Line by Green Zone 3 3
Red Zone – Static 6 2 4
Red Zone – Mobile 7 4 3
None 2 1 1
Total 25 5 5 2 1 12

7. Immediate CausePre ‐ ConditionLatent Failures

8. “Many accidents are blamed on the actions or
omissions of an individual who was directly involved in
operational or maintenance work. This typical but
short‐sighted response ignores the fundamental
failures that led to the accident. These are usually
rooted deeper in the organisation’s design,
management and decision making functions”
“Everyone can make errors no matter how well
trained and motivated they are. Sometimes we are
“set up” by the system to fail. The challenge is to
develop error‐tolerant systems and to prevent errors
from occurring”Reducing error and influencing behaviour HSG 48

9. Underlying Cause
Rules for provision of
“Morpeth” AWS magnets ‐
Morpeth North curve did not
qualify
Lesson
Not always appropriate to
prescribe rules
Morpeth 1984
Immediate Cause
Driver did not slow for 40 mph
curve

10. • Rules are required for real time operations but are not
always appropriate for planned work
• The Rule Book is the only Group Standard whose
purpose and scope is not stated. Standards should
have a defined purpose and scope
• Group Standards are required for matters “which
involve co‐operation between two or more rail duty
holders”, so work under direct control of one Railway
Group member should not be a Group Standard
• Network Rail is the employer of all those who
undertake infrastructure work and has the legal
responsibility for track safety risk controls

11. Management of Health and Safety at Work Regs
• Undertake a “suitable and sufficient risk
assessment” to develop risk controls. Further risk
assessment when circumstances change
• Provide comprehensible and relevant
information on risk control measures
Construction(Design and Management) Regs
• Provide pre‐construction information needed for
site safety
• Ensure design takes account of safety of those
who will operate and maintain completed project

12. • Rules should be derived from risk assessment as
required by MHASAW Regulations. A further risk
assessment is required when circumstances
change
• Rules are only one type of control measure. The
risk assessment must also specify other risk
control measures
• Rules and other risk controls cannot be
considered in isolation from each other. A
cohesive approach by a single authority is needed

13. AC AC – AC Electrified Lines
DC DC – Electrified Lines
OTP On Track Plant
T3 Possession of the line for engineering work
T11 Movement of engineering trains and on‐track plant
under T3 arrangements
HB1 General duties and track safety for track worker
HB3 Duties of Lookout and site warden
HB6 General duties of an Individual Working Alone (IWA)
HB7 General duties of a Controller of Site Safety (COSS)
HB8 IWA, COSS or PC blocking a line
HB9 IWA or COSS setting up safe systems of work within
possessions

14. AC AC – AC Electrified
Lines
14 sections, COSS only concerned
with issue of OLE permit
OTP On Track Plant OTP movements, on & off tracking,
safe operation of OTP
T3 Possession of the line
for engineering work
Sets up the possession needed when
work require train movements
T11 Movement of
engineering trains and
on‐track plant under T3
Movements once possession is set
up. Does not include sideways
movements into the possession
HB7 General duties of a
Controller of Site Safety
No mention of possessions.
Mandates COSS form, most of which
is not relevant to possessions
HB9 IWA or COSS setting up
safe systems of work
within possessions
Explains how SSoW derived for open
line are applied to possessions.

17. 1. Maximum speed in possession work‐sites
Not clear that the 5 mph required for a green zone only
applies to COSS’s site of work. It does not apply to entire
possession work‐site. With access points miles apart, a 5
mile round trip from access to site of work is not untypical
2. Control of On‐track plant (OTP) movements
Rule Book requires ES to authorise each move. However
there may be hundreds of individual OTP moves in a
possession work‐site. Custom and practice is for the ES to
delegate movement authority to Machine Controller .
Module T11 does consider how OTP enters possessions
and there is no requirement to record this

18. 3. Route setting in possessions
Although the route has been set incorrectly every time
a point is run through, there is no defined process to
set routes in possessions, as there is for a signal failure
on open line.
4. Red Zone working in possessions
Lookouts are for unexpected trains at high speed.
Workforce control of movements should be
considered
5. Issue of isolation permits to COSSs rather than ES
This does not take account of ES authorising COSSs to
start work and thus increases the number of
communications before work can start.

19. 1. Situational Awareness
Workforce must have a situational awareness of all aspects
of the possession. Diagrams are an effective way of
providing this especially as various limits being
demarcated in different ways
Limit Demarcation
Possession Signals and / or points numbers
Possession work‐site Mileage
COSS’s Site of Work As agreed with ES, not documented
Isolation limits (AC) OLE mast numbers
Access points Mileage
No specification for possession diagrams or process to
provide employees or contractors with the information
needed for such diagrams.

20. 1. Situational awareness
Example diagram with same information as on signaller’s panel

21. 2. Controller of Site Safety (COSS)
•COSSs need to be able to set up many different safe systems of
work (SSoW). On the open line this is a demanding role
•This is not so in an all lines blocked Possession as the SSoW has,
in effect, already been established
•Many COSSs only work in all lines blocked possessions, but to
do so they must have the full range of COSS competencies
•A suitable COSS possession competency would thus reduce
training requirement and eliminate risk of a COSS losing
competence to set up open line SSoWs due to lack of practice
•It is not feasible for many who supervise possession work to
obtain the full COSS competency and so workgroups often have
both a COSS and site supervisor managing their safety

22. 3. Facilities for PICOP / ES
• Although simple possessions can be managed from a van
by those who know their area, complex possessions need
facilities to reduce risk of reliance on human memory e.g.
an office, magnetic board with diagram and forms to track
movements and on / off tracking
• “I’d rather control a complex work‐site with facilities such
as this than a simple work‐site from the back of a van”
4. Access points
• Personnel and plant often travel miles along the railway
from access point to site of work
• Opportunities to provide access points as part of projects
are often lost with no standard requiring their provision

23. 5. Authority to Work Communications

24. • Possession rules are in various modules / handbooks
and have been evolved from the need to control train
movements with other rules “bolted on” in an ad hoc
manner. They need to be better presented and
enhanced to address issues not currently addressed
• This could be resolved by a possession safety handbook
which could be provided relatively quickly as there is
little, if any, requirement to change existing rules
• Scope of this guide should be interfaces between the
operational railway and between different principal
contractors
• The starting point for such a guide must be the
requirements of the work rather than train movements

25. RIMINI
A significant improvement in 2001 giving greater
emphasis on work planning but:‐
• Does not specify T2 hierarchy (T2A / T2D less
prone to human error than detonator protection)
• Complex paperwork
• 9 years after RIMINI introduced, there is no
process to provide asset information required for
planning

26. Lookout Operated Warning Systems (LOWS)
• Since 1994 there were 5 lookout
fatalities (20% of total), 3 of which
were mobile sites. Lookouts face
greater risks than other track
workers. Risk may be intolerable
• Lookout must be in a place of
safety and have line of sight the
workgroup and approaching
trains. This is difficult to achieve
when walking along the track

27. Lookout Operated Warning Systems (LOWS)
• LOWS does not require the lookout to be in sight of
workgroup, so the lookout need not be close to the
track
• LOWS could eliminate the need for a lookout chain
(site, intermediate and distant lookouts)
• Widespread use of LOWS could reduce risk to
lookouts and provide cost savings
• Some LOWS trials but minimal use of LOWS
• LOWS systems used are cumbersome and cannot be
used for mobile worksites. There is a need to develop
easily used portable systems

28. Track Circuit Operating Devices (TCODs)
• TCODs enable COSS on site to
directly maintain a signal at danger
• Eliminates risk of
miscommunication with signaller
• Not widely used although popular
with those who use them
• Type approval issues
• Unclear where they can be used
• Fixed TCODs are switches that
activate track circuits and is a low
cost alteration to signalling system

29. Trackside facilities
• Although significant sums have been spend on
access points, a strategy is required for the provision
of assets to improve safety and possession efficiency
• This includes access points, remotely operated DEPs,
track warning systems and lockouts
• Although these can be expensive to provide, cost can
be minimal if specified at start of project design
• CDM requires project designers to consider safety of
those working on the track. This applies to anyone
taking a design decision (e.g. Project Sponsors who
specify project requirements)

30. Despite report recommendations and improvement
initiatives over many years there have been few track
safety improvements
•Report into fatal On Track Plant accident at
Hednesford in 2004 “a review of module T3 and T7 of
the rule book should be undertaken to establish safe
systems of work which accommodate multiple
activities and train movements within worksites.”
•Rail Accident Investigation Branch bulletin on the
Kentish Town 26.10.09 possession incident notes that
its recommendations from the similar Acton 24.6.08
incident have yet to be implemented

31. Why
• Rules culture – A great strength but can lead to a blame culture
that does not allow for genuine mistakes and masks the need to
improve risk controls.
• Organisational culture ‐ Safety improvement requires a
willingness to openly identify problems. Under reporting of
hundreds of RIDDOR accidents is indicative of a culture that does
not encourage this.
• Risk not understood ‐ Suitable performance indicators for track
safety incidents are needed.
• Reluctance to accept risks associated with changed risk controls.
• Track safety rules are Group Standards subject to extensive
stakeholder communications that are produced by RSSB
committee whose focus is train movements. Only 3 of its 18
members work for Network Rail.

32. • LOWS eliminates need for lookout chains
• No duplication of site supervisor and COSS
• Avoid points run throughs
• Reduced time to start from simplified possession
communications
• Reduced travel time from access point to site of work
As well as reducing risk, suggestions in this presentation offer
productivity and cost savings. for example
Machine Controller
starting 2 mile walk
to site of work
in a freezing rain squall
ORR consider that NR’s infrastructure work 34% to 40% less
efficient than in Europe, in part due to way possessions are
undertaken.

33. • Network Rail, as the responsible employer,
should take ownership of track safety at
Director level to ensure a cohesive approach
to rules and other risk controls, a culture that
encourages safety improvement and a
strategy for the provision of track safety
assets and systems
• This should be based on risk assessment,
legislative requirements, address issues in this
presentation and incorporate lessons from
previous initiatives