RAIB’S ANNUAL REPORT SHOWS NO ROOM FOR COMPLACENCY

This year’s Railway Accident Investigation Branch (RAIB) annual report shows that, in 2022, there were 16 railway accidents on the main line network requiring RAIB investigations. During the year the Branch published 14 full reports and 8 safety digests as shown in table 1.

The report describes how RAIB had published nine ‘Summaries of Learning’ (SoL). These address the most significant areas for which RAIB has concerns about the control of risk due to recurrent issues since its first investigations in 2005. Table 2 shows the relationship between these themes and those of RAIB’s annual report which form the basis of this feature which primarily concerns incidents on the GB main line railway network. However, RAIB’s remit also covers Metros, Heritage Rail, the Channel Tunnel, and Northern Ireland. In 2022 it considered five Metro accidents as shown in table 3.

Graph 1 shows the significant reduction in fatal train accidents over the past 50 years and how the Train Protection Warning System (TPWS) has reduced such accidents. Whilst fatal train accidents are rare, other types of fatal accidents regularly occur on the national rail network, for example workforce, platform, and user worked crossing accidents. Table 4 shows a 37% reduction in such rail fatalities over the past ten years. Yet, sadly, annual suicides have increased from 216 to 261 over this period. Whilst this safety improvement is good news, RAIB’s annual report shows that much more needs to be done, especially as, in slightly different circumstances, some accidents could have been multi-fatality events.

Railway Operations

Table 2 shows how operations accounted for the highest number of accidents considered by RAIB in 2022. These included two buffer stop collisions and two signals passed at danger. Maintaining full concentration whilst driving trains is a demanding task. Hence RAIB recommends research into the detection and mitigation of driver’s loss of attention, and support for drivers in respect of fatigue and lifestyle management.

TPWS was implemented over 20 years ago as a stop-gap measure until the implementation of automatic train protection provided by ETCS. Although it is not a failsafe system, it has significantly reduced operational risk. Yet, with widespread ETCS deployment remaining many years away, RAIB questions whether TPWS provides sufficient risk mitigation.

An overspeeding incident at Peterborough in April 2022 showed how neither TPWS nor current signalling standards provided sufficient risk mitigation for a train routed from the Up Fast to the Up Slow line. As the train approached the junction control signal was displaying in red aspect until the train was 790 metres away travelling at 25mph. It then changed to a green aspect with its junction indicator (a string of five white lights) showing that the train was routed on to the Up Slow. The driver did not react to this indicator and then applied power which accelerated the train to pass the signal at 64mph, after which it passed over a set of points restricted to 30mph at 76mph.

FIGURE 1 - Driver did not react to this signal’s junction indicator when its red aspect changed to green CREDIT: RAIB

Thirteen months later, there was another overspeeding incident at this signal. Since then, the approach control at this junction control signal has been changed to display a yellow aspect when a route requiring the junction indicator to be illuminated is set.

Track Worker Safety

Since 2005, RAIB has investigated 58 incidents involving track workers and moving trains. Of these, 10 resulted in deaths and 12 in injuries. The SoL showed that the safe system of work in place during these incidents included 24 instances of unassisted lookouts, 12 possessions, and 12 line blockages. It identified the following concerns:

» Planning work.

» Quality of site leadership.

» Supervision and monitoring of track workers.

» The way information is presented to track workers.

» Standards of lookout working.

» Staff installing possession protection equipment.

» Management of contingent labour.

» Staff willingness to challenge unsafe practices.

The fatal accident at Surbiton in February 2021 was followed by five track worker near misses, investigated in 2022. The Surbiton report showed that the individual killed was working outside the protected area and recommended action to keep track workers within safe limits. It also recommended that Network Rail review working practices to understand reasons for non-compliances. This, and previous reports, highlighted the need to reduce the amount red zone working.

FIGURE 2 - Cab video shows track worker near miss at Paddington CREDIT: RAIB

RAIB’s annual report notes that improved technology and planning reduce the occasions that workers are on track when trains are running. However, as RAIB’s chief inspector Andy Hall notes: “whether working in planned red zones or not, lower-level risk controls relating to safety behaviours and site safety leadership remain important, if we are to avoid the type of near miss we continue to see, that one day may turn out to be another tragedy.”