RAIB outlines safety lessons from near miss at Devon boat yard

The Rail Accident Investigation Brain (RAIB) today released its safety digest into a near miss at Teignmouth Boat Yard[1], Devon, on Tuesday 14 February 2023.

RAIB has released this short video summarising its findings.

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RAIB believes that the incident demonstrates how important it is that:

  • workers are only required to undertake tasks that involve accessing the railway if those tasks are unavoidable
  • all involved reach a clear understanding of the operational status of the railway before going on or near the line
  • all involved follow good practice in safety-critical communications, regardless of the regularity of the arrangements being made or how familiar the staff involved are with each other
  • prompt use of the train warning horn, which in this case probably avoided a fatality.

What happened?

At around 01:23 hrs on 14 February 2023, a passenger train travelling at 55 mph (88 km/h) narrowly missed a track worker on the down main line near [2] station, Devon.

The near miss occurred while a work site was being set up, at a location where workers access the railway through a private boat yard. Similar arrangements were used regularly to allow the use of road-rail vehicles (RRVs) and an overhead crane during the building of a new rockfall shelter over the Great Western Main Line.

The track worker was placing a work site marker board on the six-foot rail of the down main line when the near-miss incident occurred.

The worker did not sustain any physical injury, but had to jump into an adjacent line to avoid being hit by the train, which collided with the work site marker board less than two seconds after the track worker jumped clear.

What were the causes?

The RAIB found that the track worker had incorrectly assumed that the line had been blocked to rail traffic. Several conversations took place between the track worker and the responsible Engineering Supervisor (ES) before the worker placed the marker board, but none of these conversations prevented the incident from occurring.

Confusion arose as to whether RRVs were to be used during the work, and therefore whether marker boards would be needed.

RAIB concluded that “This incident occurred because the informal method of communication had led to two assumptions being made. These were the assumption made by the track worker that the line was already blocked, when being asked to set up the work site marker boards, and the assumption by the ES that the track worker would await further instructions before accessing the railway. This informal communication between the track worker and ES arose due to their familiarity with each other, their good working relationship and because they had been applying the same work site arrangements almost every night for several months.”

Has this happened before?

RAIB points out that it has previously investigated several accidents and incidents involving track workers, a number of which are listed in this report of an incident at Paddington last year[3]. A near miss at Sundon, [4] in 2019 (RAIB Safety Digest 05/2019) is particularly relevant to the [5] incident, as the people involved had not reached a clear understanding during safety-critical communication, which caused the incident. As with the Teignmouth incident, the sounding of the train horn probably averted a fatal accident.

Readers can access the full document here[6].

References

  1. ^ near miss at Teignmouth Boat Yard (www.railadvent.co.uk)
  2. ^ (www.railadvent.co.uk)
  3. ^ this report of an incident at Paddington last year (www.railadvent.co.uk)
  4. ^ (www.railadvent.co.uk)
  5. ^ (www.railadvent.co.uk)
  6. ^ here (www.gov.uk)

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