Rail Accident Investigation Branch (RAIB) has advised Keltbray Infrastructure Services (Aureos) to change how it plans its work by railway lines.
This is among a series of recommendations to arise out of what was nearly a fatal accident last year, with Keltbray workers dicing with death.
At about 09:53 on 23rd April 2024, a train travelling at 104 mph came very close to striking a track worker who was crossing an underbridge at Chiltern Green, between Harpenden and Luton Airport Parkway stations. The track worker was just stepping off the bridge, from an area where there was very little space between the bridge parapet and track, when the train passed by.
On seeing the track worker on the bridge, the driver sounded the train’s horn and applied the emergency brake. Once the train stopped, the driver reported the incident to the signaller, unsure as to whether he had hit the track worker.
At the time of the incident, the track worker, who was a tester carrying out telecommunications cable testing, was walking to rejoin their group after a welfare break. RAIB found that the tester chose to walk over the bridge because they were unaware of any other way to walk back to the rest of the group and because the person in charge had not arranged for the tester to safely leave and rejoin the group when taking a break.
The person in charge had previously taken the tester over the bridge using an informal and potentially unsafe system of work, using a route that was not the one that the project engineer had intended the group to use. This happened because the staff involved were unfamiliar with one of the locations, the person in charge had a limited role when the work was planned and had not been briefed , and the documents issued to the person in charge did not give a clear description of the route that the team was expected to walk to the site of work.
RAIB found that the tester had crossed the bridge without an effective safe system of work in place despite being aware of the risks in doing so. However, the tester’s personal track safety competency, and the associated rules for walking alone on or near the line, did not prohibit them from crossing a structure with restricted clearance. RAIB also identified that the bridge was not signed as a limited clearance structure, which was a possible factor.
An underlying factor was that the overall methodology followed for planning the work did not provide the person in charge with clear information about how to carry out the walking element of the work, RAIB said. A possible underlying factor was that, although Network Rail had recorded the bridge as having restricted clearance, it and many other structures on the railway between London and Bedford were not fitted with the required signage to warn staff of this hazard.
RAIB also observed that:
- Historically, the rail industry has fitted limited clearance signage to structures with restricted clearance if they can be crossed safely while trains are running by using one of the warning safe systems of work, which are now much less commonly used.
- Network Rail’s record of its warning signs on its East Midlands route is incomplete, and it has no inspection or maintenance regime for these signs.
- After the incident, the track workers then walked over the bridge again while trains were still running, without an adequate safe system of work in place.
Since the incident, changes to the rules were published to prohibit crossing a bridge with restricted clearance unless an appropriate safe system of work is in place.
As a result of the investigation, RAIB has made four recommendations. The first is for Keltbray Infrastructure Services to review and amend how it plans work on or near the line, so employees better understand how to manage and carry out the work they need to do. (Keltbray Infrastructure Services has a new owner since the incident. It was sold by Keltbray to EMK Capital in August 2024 and rebranded as Aureos in December.)
The second recommendation is for the Rail Safety & Standards Board to follow the relevant rail industry processes to review and amend as necessary the rail industry standard requirements for warning signage at structures with restricted clearance.
The third is for Network Rail to record its lineside signs, determine what inspection and maintenance regime is required for these assets, and then schedule these activities to be done.
The fourth, also addressed to Network Rail, is to reduce the risks to railway staff due to warning signage not being fitted to structures with restricted clearance.
RAIB has also identified four learning points.
The first reminds staff involved in planning or carrying out work on or near the line of the importance of coming to a clear understanding about how the planned activities, including the walking elements, should be done.
The second highlights the importance of providing information that clearly identifies the access points to be used if the planned activity involves staff going to more than one access point and different sites of work.
The third highlights the importance of not going into any area where there is reduced space between a structure and the nearest running rail of an open line.
The fourth highlights the importance of track workers, who are involved in a near miss incident with a train, understanding how they will safely exit the railway, and seeking assistance from the signaller if required.