HomeGovernanceAccident InvestigationRAIB annual report makes sombre reading

RAIB annual report makes sombre reading


The Rail Accident Investigation Branch, which investigates accidents to discover why and how they occurred so as to learn from them and make the railways safer, has issued its annual report for 2019.

It wasn’t a good year. After several years without a fatal accident involving workers on the railway, there was suddenly a spate of them.

Simon French, RAIB.

In his introduction, chief investigator Simon French said: “I am sorry to report that 2019 saw some major setbacks on the path to improved safety for railway employees.

“In July, all of us at RAIB were shocked to hear that two track workers had been killed by a train at Margam in South Wales. Three men were undertaking routine maintenance activities on a main line that was still open to traffic, and none saw the approach of the train until it was too late. We immediately deployed a team to site and launched our investigation.

“Our role is clear, to provide an independent investigation of the factors that led to the accident and the underlying management issues. I am determined that RAIB recommendations will promote the changes that are needed to make track worker deaths a thing of the past.

“The year 2019 ended on another sad note with the death of a train driver who was caught between two trains as he walked between them at Tyseley depot in Birmingham on 14 December 2019. On 8 April 2020, RAIB deployed to the site of another tragedy, a fatal accident involving a track worker who was struck by a train near Roade, in Northamptonshire. Our investigations are currently underway.

“My thoughts are with all those affected by these terrible accidents.”

So RAIB has three fatal accidents to investigate.  It will be some time before reports are issued – in 2019, the average time taken to publish full reports was 10.7 months from the date of occurrence – although that means the Margam report must be close.

RAIB is busy enough without the added pressure of finding the cause of these dreadful accidents. During the period from 1 January to 31 December 2019, investigators received 381 notifications of railway accidents and incidents from the industry, resulting in 51 preliminary examinations. As a result of its analysis of the information gathered, RAIB started 13 full investigations and 10 safety digests.

A total of 17 full investigation reports were published in 2019, along with one interim report, 10 safety digests and one urgent safety advice notice.

It’s too easy to view RAIB reports as dry, factual accounts of the details of an accident with a list of recommendations at the end. Certainly, a tremendous amount of work goes into them and the investigation is painstaking and thorough – one reason why it takes 10.7 months to publish one. But investigators are human, and often they are investigating a human tragedy.

Simon French remembers visiting the site of a fatal accident involving a track worker some years ago: “I had seen the aftermath of fatal accidents before and was to see more in my career as an RAIB investigator. However, investigating the death of a fellow railway industry professional had a profound effect on me. The railway is like a family, with a distinct culture all its own, and we all feel deeply the loss of our colleagues. It’s especially traumatic for those who witness such accidents, including workmates and train drivers.’

Learning from other railways

“There is no great mystery about the areas that need to be addressed to improve the safety of track workers,” Simon writes in the Annual Report. “These 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.

“Some railways, such as the London Underground and the Docklands Light Railway, already impose much stricter separation between people and trains. Consequently, neither has ever featured in an RAIB investigation in which track workers were at risk from moving trains.

“Other European railway systems, such as in France, timetable ‘white periods’ in the daytime off-peak hours during which no trains are scheduled to run, so enabling safe access for inspection and maintenance purposes. In other cases, reduced train services are directed over bi-directionally signalled lines, or diverted onto alternative routes, to enable access in daylight hours.

“Daytime line blockages for routine inspection and maintenance are hard to come by on the heavily trafficked parts of our national network, and so it is often much easier to arrange safe access to the infrastructure at night, when fewer trains are operating.

“Despite this, many routine maintenance activities continue to be carried out during the day, when opportunities to block the line are much reduced. Cyclical and pre-planned activities, like replenishment of lubricators, continue to be carried out in the middle of the day by a worker who is required to ‘nip in’ between high-speed trains, while two or three colleagues are employed to look out.

“This is not only potentially unsafe, it can be inefficient because the work activity is constantly being interrupted.”

The full, 34-page report can be downloaded here.


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