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14.08.15

RAIB says Network Rail must review handback after engineering works

Network Rail has been told to look into its process for handing back sections of engineering work after a train was hit and damaged by an equipment cabinet door in Watford Tunnel last year. 

Following the collision on 26 October 2014, an RAIB investigation found that the cabinet door had blown open as the train passed, probably because the door had been left closed but unsecured after being worked on the night before. 

When the 06:42 Milton Keynes Central to Euston passenger service was passing through Watford Tunnel, the cabinet door detached from its hinges, hitting the side of the train and damaging a door on the fourth carriage. Passengers in this carriage reported being “showered” by flying glass from the damaged train door, but there were no injuries. 

Glass shatter

RAIB identified a number of reasons why the door had been left unsecured, including poor task lighting, no-one being allocated the responsibility for checking that cabinet doors were closed and secured, and the possibility that the staff involved may have been tired. 

Siemens was responsible for the project management, design and installation of works and equipment associated with the re-signalling project in the Watford area. RAIB added that it had not fully implemented its policy on fatigue management, with testers not being given 48 hours rest after their block of night shifts, for example. 

The investigators said: “Siemens UK should commission an independent review of the implementation of those aspects of its safety management system relating to the welfare of safety critical staff working on infrastructure projects, including its arrangements for managing fatigue, and take action as appropriate to rectify any deficiencies found.” 

With regards to Network Rail, RAIB recommended it should look into processes for handing back sections of railway after engineering work, its policy on locating lineside equipment in areas of restricted clearance, the design of lineside equipment for areas of restricted clearance and improvements to its product acceptance processes so that previously undertaken risk assessments are available to future users of individual items of equipment. 

Cabinet before and after

RAIB said: “Network Rail should implement a means to meet the rule book requirement for the designated person (Engineering Supervisor or Safe Work Leader) to confirm to the Person In charge of the Possession that the railway is safe and clear for the passage of trains when that designated person is not present on site.” 

Additionally, it has been suggested that Network Rail in conjunction with Henry Williams Ltd, the manufacturer of the cabinet involved, should make sure that it has full details of the certification of its products used on the railways. 

Matthew Kent, Delivery Director Central at Siemens Rail Automation, told RTM: “Siemens accepts the findings of the RAIB investigation and we have already carried out the recommendations highlighted. The safety and well being of our employees as well as the travelling public is paramount. We will continue to review and have independent bodies in place to audit our processes and procedures to avoid such an incident occurring again in the future.”

UPDATE

A Network Rail spokesperson told RTM: “As a result of this incident,  we have already taken a number of actions. Safety is our highest priority and where we can make improvements to the way we work, we always seek to do so. 

“The recommendations in the RAIB report will be carefully considered and we will take action where necessary.”

(Images: From the RAIB investigation report)

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