A report has been released by the Rail Accident Investigation Branch in regard to an incident which took place at London Paddington station and saw a near-miss involving track workers.

The incident took place at 01.17hrs on the 18th of July 2022 when a passenger train travelling at 24mph was making its way into London Paddington station, narrowly missing two track workers who were walking very close to the line with their backs facing the train as it approached.

The driver of the train sounded a second audible warning before the track workers acknowledged the train’s approach and moved out of its path just one and two seconds before reaching the worker’s location.

The Network Rail track workers involved in the incident were working in a team of four people and were carrying out maintenance for signalling and telecommunications equipment 0.8 miles to the west of Paddington station. The group were led by a Person in Charge or PIC who are responsible for the supervision and overseeing of the safe implementation of work. The Person in Charge was also carrying out the role of Controller of Site Safety or COSS, and is the person who is accountable for establishing and maintaining safe working systems in order to ensure that track workers are protected from train movements. Three further members of the group were carrying out the work which included the two team members involved in the incident.

Of the two track workers involved in the near miss, one was inexperienced and was wearing a blue helmet whilst working close to the line. Inexperienced track workers are supported and mentored until they are able to demonstrate the knowledge, skills and behaviour needed in order to work safely.

The incident took place as the two track workers had moved from lines which were blocked to rail traffic and ended up walking extremely close to an operational line. The Person in Charge who was also the Controller of Site Safety had not planned the work or supervision of the group well enough while they were completing work on the track. The team did not raise any issues as to the unsafe nature of their working system set up by the Person in Charge or in regards to the unsafe behaviour of group members.

Initially, two Signalling and Telecommunications teams were supposed to access the tracks close to Paddington station as part of a possession which is when the railway is blocked to service trains in order for engineering work to be carried out. Despite this, when the two teams met at a depot close to Paddington station at 18.00 hours on the 17th of July they opted to work as single Signalling and Telecommunications team using just one of the two Persons in Charge that had been assigned to the teams due to staff shortages.

With more than six hours to prepare ahead of starting the work, the Signalling and Telecommunications team did not take into consideration whether the work previously given to the two teams could be carried out safely with the remaining staff available and in compliance with planned safe systems of work. None of the Persons in Charge who were responsible for the two original teams told the manager who had previously approved their safe systems of work of their plans to change their activity. The Person in Charge/Controller of Site Safety responded for the newly formed single team and also did not inform or pass on the information contained in the relevant safe work packs which are used to record the safe system of work. This is a procedure required by Network Rail’s procedures and specifically relating to standards NR/L2/OHS/019 issue 10 dated 5 December 2020 ‘Safety of people at work on or near the line’.

The Signalling and Telecommunication team entered the track via platform 10 at Paddington station at approximately 00.35hrs on the 18th of July. The team inspected the axle counters for lines 4, 5 and 6 for 0.2 miles west of the station. This work was originally assigned to the first of the two Signalling and Telecommunications teams and was carried out using a separated safe system of work and was arranged for lines 4, 5 and 6 which the team were working on and were blocked under the possession, however, the adjacent lines, 1, 2 and 3 were still open to traffic.

Part of a separated safe system of work sees a site warden appointed in order to warn team members should they attempt to move into an unsafe location which is within two metres of an operational line. The Signalling and Telecommunications team were not allowed to step into the six-foot which is the space between two adjacent tracks, which separated line 4 which was blocked to traffic as well as lines 5 and 6 and line 3 which was still open. If the track workers have tried to move into the six-foot they would usually have been warned via the site warden, alerting them to return to their designated safe area.

The Person in Charge/Controller of Site Safety had also given himself the job of site warden. According to Handbook 7 of the Rule Book ‘GERT8000-HB7’, ‘General duties of a controller of site safety’ issue 6 dated September 2019′ says that ‘if you act as a site warden you must take no part in the actual work’. Further to this, a frequently asked question’s supplement to NR/L2/OHS/019 is very clear that being a Person in Charge constitutes taking part in actual work. This important detail demonstrates that the Person in Charge/Controller of Site safety was actually not allowed to work as a site warden as stated by the Rule Book and by the Network Rail standard.

00.50hrs saw the team complete the axle counter inspection which took place earlier than planned due to the Person in Charge/Controller of Site Safety deciding that there was time to carry out the maintenance work which had previously been given to the second Signalling and Telecommunications team.

The team walked to a signal post telephone which was 0.8 miles away from Paddington station where the Person in Charge/Controller of Site Safety told three members of the team to carry out an inspection of the telephone before walking back to Paddington station independently. While the team followed their instructions, the Person in Charge/Controller of Site Safety inspected paperwork in a railway equipment building (REB) some 20 metres west of the work site and also elected to take a personal needs break ahead of walking back to Paddington station to rejoin the team.

The Person in Charge/Controller of Site Safety’s instructions meant that he could no longer carry out the role of Controller of Site Safety effectively and this role meant that he would have to stay with the group. The three track workers who headed to inspect the signal post telephone did have a qualified Controller of Site Safety and site warden, the Person in Charge/Controller of Site Safety had not appointed anyone to take on these positions once he left the team. Members of the group did not question this unsafe approach to working despite two members of the group being experienced and holding the necessary knowledge/experience to know that this was not safe and did not follow the relevant rules.

Once the Person in Charge/Controller of Site Safety left the group, they completed the maintenance of the signal post telephone before making the walk back to Paddington Station. One track worker walked in the four-foot which is the space between the rails, of line 5, and the other two track workers walked in the four-foot of line 4 due to conditions underfoot being better. At approximately 0.6 miles from Paddington station, the group encountered a six-person permanent way team who were also working in the possession and had a hand trolley on line 4. The inexperienced track worker of the signalling and telecommunication team was wearing a blue helmet and was walking ahead of the experienced team members, one of the team members was close to him on line 4 whilst the other was approximately 20 metres behind him on line 5.

The two track workers walking on line 4 made their way to the trolley and stepped out into the crossover between lines 4 and 3. Stating that he was aware that line 3 was open to approaching traffic, the inexperienced track worker still opted to walk between the lines as it provided an easier route. The experienced track worker reported that he had unintentionally followed the inexperienced worker as he lost concentration and both workers then continued to walk in the crossover for approximately 10 metres, neither aware that train 2P97 was on line 3. It is unclear why the two track workers remained in the crossover after making their way past the trolley.

Train 2P97 data recorder provided evidence alongside forward-facing CCTV images showing the train making its way to Paddington station at approximately 01.17hrs. Both the Signalling and Telecommunications teams and the permanent way teams could not be seen in the driver’s field of view until approximately 24 seconds prior to the train reaching their location, this was due to the train approaching the teams on a curve. Four seconds after the track workers became visible the driver sounded the train’s horn in order to alert them to the train’s approach and was travelling at 36mph. Five seconds prior to the near miss, the train was travelling at 32mph and the driver once again sounded the horn and then made an emergency brake application just one second later.

The driver said that initially, he believed all track workers to be on line 4, however, as the train approached he recognised that two of the track workers were in extremely close proximity to line 3. The curve of the track, dark conditions and the reflective nature of the train’s headlights hitting a number of people wearing high-viz clothing also made it harder for the driver to distinguish the two track workers walking close to line 3 from the larger group of workers on the blocked lines.

It is unknown why the two track workers didn’t move when the driver sounded the first warning and when the driver sounded the second warning it was the more experienced track worker had just stepped off of line 3 into the four-foot which also suggests that he was not aware of the danger of the train approaching. On the second warning horn, both track workers acknowledged the approaching train immediately, moving clear of the train’s swept path.

The train driver immediately reported the near miss and the track workers and in accordance with Network Rail’s drugs and alcohol policy at the time of the near miss (NR/L1/OHS/051, dated March 2016), all four of the Signalling and Telecommunications team were tested. Three of the track worker’s results came back with a negative result, however, the inexperienced track worker did test positive for a recreational drug.

Incidents similar to this have been investigated by the Rail Accident Investigation Branch such as:

• On the 14th of January 2022, a passenger train travelling at 95 mph narrowly missed two track workers but went on to strike a tree they had felled, at Uphill Junction, Somerset. The tree’s location required a site warden to be appointed, however, the Controller of Site Safety had stood down as the group’s site warden prior to the tree being cut down.
• On the 22nd of July 2021, an empty passenger train was travelling at 69 mph and narrowly missed two track workers who were working close to the edge of a platform at Eccles station, Greater Manchester. The track workers were working under a line blockage which had been taken by a Controller of Site Safety. On handing back the line blockage, the Controller of Site Safety told the signaller that all staff were clear of the line despite not telling the track workers to move to a position of safety or being in a position to see the workers personally.
• On the 18th of September 2017, a passenger train travelling at 125 mph encountered three track workers on Dutton Viaduct, Cheshire. The last of the workers moved clear of the track just half a second before the train passed. The track workers had gained access to the track using an unplanned way and were working outside their planned safe system of work.
• On the 4th of December 2012, a passenger train struck and fatally injured a track worker who was carrying out the role of Controller of Site Safety at Saxilby, Lincolnshire. A group of five track workers had been working under a line blockage with an adjacent line open to traffic. Prior to the accident and during an initial line blockage, the Controller of Site Safety had put in place a separated safe system of work, appointing himself as the site warden. During a second line blockage, the Controller of Site Safety had not put in place a safe system of work and was struck by a train whilst working in the six-foot between the two lines. None of the other track workers questioned the absence of a safe system of work or the actions of the Controler of Site Safety.

The incident demonstrates that it is vital that Persons in Charge and Controllers of Site Safety who ensure that deviations from the planned safe systems of work are sanctioned by a responsible manager. It is also essential that Controllers of Site Safety are always with their work group whilst they are on or close to the line in order to ensure that they can personally see the team and monitor them. The incident also raises the fact that it is important the rail staff challenge unsafe work practices and that safety-critical staff act in accordance with their employer’s drug and alcohol policies.