The RAIB has released their final report into an accident which saw two rail workers fatally injured after being struck by a train in South Wales.

At 09:52 on Wednesday 3rd, July 2019 two track workers were killed after being struck by a passenger train at Margam East Junction on the South Wales Main Line.

A third track worker came close to being struck but thankfully escaped in time. The workers were part of a group of six carrying out maintenance on a set of points. The train driver applied the emergency brakes around 9 seconds before the accident and continued to sound the trains horn as they approached the track workers at around 50 mph.

The accident happened because the workers were working on a section of track open to traffic and were working without ‘lookouts’ to warn them of approaching trains. All three workers were wearing ear defenders due to the noisy machinery and all had become focused on the task in hand.

None of them knew about the train approaching until it was too late, and subsequent acoustic measurements showed that they would not have been able to hear the train horn.

The investigation found that several factors led to the situation, relating to the work itself, the way the work was planned and authorised, as well as the lack of effect challenges by the colleagues onsite.

Four factors were identified by the RAIB:

• Network Rail had not adequately addressed the protection of track workers from moving trains. The major changes required to fully implement changes to the worker safety were not implemented across Network Rail’s maintenance organisation.
• Network Rail has focused on technological solutions but had not taken into account the variety of human factors that can affect working practice.
• Network Rail’s safety management system was not effective in identifying the unsafe working practices, and did not trigger the management actions needed to address them.
• Although Network Rail identified the need to take more action regarding track worker safety, these had not led to any changes being made before the Margam accident.

The RAIB has made 11 recommendations, with 9 being addressed to Network Rail. These cover:

• Improvement to its safe work planning processing and also the supervision of maintenance staff
• Renewing its focus on developing the safety behaviours of front line staff
• Establishing a group to provide vision, guidance and challenge its initiatives for safety.
• Improving the assurance processes

Simon French, Chief Inspector of Rail Accidents said: “The death of the two track workers who were struck and killed by a train at Margam was a tragic loss for their families and friends. It has also had a profound effect on all of us at RAIB, and those who died and all those who were close to them, are in our thoughts. The railway is like a family, with a distinct culture all its own, and we all feel deeply the loss of colleagues.”

“This accident has reinforced the need to find better ways to enable the safe maintenance of the railway infrastructure. The areas that need to be addressed to improve the safety of track workers have been repeatedly highlighted by 44 investigations carried out by RAIB over the last 14 years. The most obvious need is for smart and accurate planning to reduce the frequency with which trains and workers come into close proximity, while also meeting the need for access to assets on an increasingly busy railway system.”

“I believe it is essential that Network Rail addresses the fundamental requirements that have been highlighted by RAIB’s investigations over the years.”

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