Cultural factors and poor working relationships between machine operators and controllers have been identified as significant factors in a MEWP collision
The Rail Accident Investigation Branch (RAIB) has published its report into the MEWP collision that took place in Rochford on 25 January.
At 10:57am a mobile elevating work platform (MEWP) collided with a stationary machine of the same type on which two people were installing overhead line equipment. They both suffered minor injuries.
The machine operator in charge of the MEWP had lost focus while driving the machine and was alerted by other members of staff shouting at him to stop. At that point, the machine was travelling too fast to stop before striking the stationary MEWP.
The machine operator had driven away from the machine controller, who was responsible for the MEWP’s movements, without permission, and drove the machine at around 10 mph while using the onboard CCTV screen to view the route ahead. These actions were contrary to the applicable operating rules.
RAIB said that ineffective supervision of the machine operator and confusion among staff about who was in charge of the safe movement of on-track plant on the site led to the MEWP collision.
Cultural factors on the site led to poor working relationships between machine operators and controllers and an excessive focus on ‘getting the job done’, rather than compliance with rules and operating standards.
Network Rail’s assurance processes had not identified these issues.
- Review and clarify the roles and responsibilities of staff working in possessions and worksites to avoid duplication of responsibilities and confusion arising between roles.
- Network Rail should undertake a review of the way that the Sentinel scheme is managed, in respect of incident investigations and how training providers and primary sponsors assess the English language skills of staff who undertake safety-critical duties
- Network Rail (Anglia) should review its reporting and response process for accidents and incidents
- A review of the equipment currently used to alert staff to a dangerous situation within a possession or work site
- Commission an independent review of the internal culture and working practices of Network Rail’s Overhead Condition Renewals business unit.
‘A catalogue of errors and omissions’
Simon French, chief inspector of Rail Accidents, said: “Although the consequences of this accident were minor, the people who were in the machine that was struck could easily have been killed if they had not been wearing their safety harnesses.
“Our investigation found a catalogue of errors and omissions which could have had much more serious consequences.
“We found duplicated lines of control, leading to confusion and a lack of clarity about who was in charge of the work and the machinery that was being used.
“As well as the safety risk this creates, it’s also inefficient and wasteful. Network Rail needs to find a more effective way of managing the movements of multiple vehicles in work sites.
“It was particularly disturbing to find underlying evidence that racial, language and cultural tensions were factors in the accident at Rochford.
“Safety relies on mutual respect within teams, for each other and for each person’s role. If this is lacking for any reason, then as well as creating a culture of disrespect, it creates an environment in which accidents are more likely to happen.
“I am pleased that Network Rail has already recognised this problem in one of its subsidiary companies and is taking action to improve the situation.”