Interim report on Port Talbot track worker fatalities reveals “there was no safe system of work in place”

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Interim report on Port Talbot track worker fatalities reveals “there was no safe system of work in place”

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Network Rail has released an interim report into the fatalities that occurred at Margam, near Port Talbot in South Wales, on 3 July 2019.

It looks into what happened on the day and why and how the accident occurred. The full report, which will be released in a couple of months, will explore the underlying causes and will make relevant recommendations.

On the day in question, thirteen permanent way staff left Port Talbot depot to work at Margam (20 mins away). They arrived just after 08:00, whereupon the team split into two, with one team of seven working in a planned line blockage at Margam Moor while the other group of six deployed to Margam East Junction.

Some time later, three of the six were using a petrol-engine impact driver to tighten bolts in a crossing. They were all wearing ear defenders due to the high noise levels. When a bolt seized, they all became focussed on the task with no-one looking out.

Unnoticed, a GWR train approached the site at approximately 70mph. Two men, Gareth Delbridge, 64, and Michael (Spike) Lewis, 58, were struck and fatally injured while the third escaped impact with just inches to spare.

How did it happen?

Work had been planned to take place at the Margam East Junction site during the afternoon in a line blockage. But the safe work pack contained a second option, to work with unassisted lookouts that afternoon.

One of the six team members was asked to be the Person in Charge (PIC). He appointed another team member as the COSS (Controller of Site Safety).

The COSS was told to use the second system in the safe work pack and appointed distant and site lookouts.

The team of six on site at Margam East Junction decided to do extra work that wasn’t in the plan, some of which involved noisy plant to maintain bolts in a crossing.

A group of three, including the COSS, site lookout and another, moved about 150 yards away, leaving their colleagues to wait for their return.

However, the three left at the points started to work on the crossing bolts. There was no appointed COSS with them, no safe system of work and no distant lookout in place.

The Person in Charge said he would look out then became involved in the work, focussing on the bolts. None of them saw the train coming.

Track layout at Margam East Junction. The technicians were split into two groups and the three working on the Up Main didn’t hear the train approaching.

The train driver initially gave warning to the track workers using the high and low tone of the train horn but thereafter used the low tone for two long, continuous blasts as the train approached the work group. The investigation team note the requirement in the Rule Book for the high tone to be used to give an urgent warning to anyone on or dangerously near to the line. The Rule Book specifies: “Give a series of short, urgent danger warnings to anyone…who does not…appear to move clear out of the way of the train.”

It is uncertain whether a series of short high tone warnings, rather than continuous sounding of the low tone, could have resulted in the track workers becoming aware of the train earlier.

Various other anomalies are included in the report.  These include:

  • The Safe Work Pack did not specify all of the work and how it was to be safely undertaken;
  • The COSS was only appointed that morning;
  • The COSS had his authority undermined – the PIC didn’t believe a distant lookout was needed;
  • The work was started in the morning, not the afternoon as planned;
  • There was no safe system of work in place;
  • The COSS was not with the group involved when the accident occurred;
  • The group all became focussed on the task and were unaware of an approaching train;
  • The wide experience of the closely-knit group and familiarity with each other potentially affected their perception of risk.

There are still facts to be determined, and questions to be answered, which will hopefully be included in the full report when it is published.  In addition, the Rail Accident Investigation Branch (RAIB) is conducting its own report into the accident, though these typically take around 10 months to be issued.

The Office of Rail and Road (ORR) has also stated that it is undertaking an investigation.

Reaction

On the release of the interim report, Martin Frobisher, Network Rail’s safety director, said: “The whole railway family shares the loss of Gareth and Spike. Nothing will lessen the pain but understanding what went wrong and learning from that will, I hope, go some way to reassure all those affected that we will do all we can to stop it ever happening again.

“Today is the first step in that journey as we share an initial investigation into what happened. We will continue for several months to look deeper into the root causes before we make recommendations for our organisation and all of our people for the future.”

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