I report with great sadness that four industry workers lost their lives at work. Two were electrocuted and two were killed in occupational road accidents. The electrocution fatalities were tragic, but avoidable events and are still subject to our investigation. We challenge the sector to better manage electrical safety and occupational road safety.
Network Rail continues to show strong leadership in suicide prevention, collaborating closely with partners including the Samaritans. However, I note sadly there was a 5% increase in suicides and suspected suicides - the highest level ever recorded. This compares to a consistently lower level of suicides on London Underground.
Transport for London has maintained a high level of safety for its passengers and workforce as passenger numbers and services grow. We took more enforcement than expected on London Underground’s construction activities. Its management response was mature, but it highlighted the challenge of operating a safe and busy railway during a very significant long-term investment programme.
We set up specialist teams to look at Network Rail’s work on level crossings, track, civil structures and electrical and workforce safety. These have proved very effective and will ensure the challenges of Control Period 5 (CP5) 2014-19 are met without compromising safety. Our train and freight operator, metro, heritage and Transport for London teams are focused on their specific risk areas, such as station safety, driver management and workforce safety.
We have developed a programme to manage our approach to safety by design. It includes an experienced senior inspector to lead our monitoring of High Speed 2’s (HS2) design. We revised our memorandum of understanding with the Health and Safety Executive (HSE) to clarify our role in enforcing road vehicle incursions on the tracks and are developing a new agreement to take enforcement on design aspects of new-build projects.
Level crossings
“Passenger risk does appear to have gone up slightly, but that is because the numbers have gone up,” says Ian Prosser, Director of Rail Safety, Office of Rail and Road. “But when you normalise the stats, risk is slightly down. Something is working, and that’s because Network Rail - in some areas - has made some really quite key improvements.
“Level crossing risk has improved, for instance. But there are problems elsewhere - we need to maintain momentum on renewals in particular, and maintenance. NR is starting to make headway on earthworks after we had to enforce on drainage last year. They are making progress with drainage.”
It is important that the risk reduction momentum is maintained, including the focus on crossing closures, downgradings and improving users’ understanding of the risks. Further strategic improvement will be driven by DfT’s implementation of the Law Commission’s level crossing safety report recommendations originally made 2013.
Crossing closures and downgrading form an important part of this ongoing risk reduction strategy - 256 crossings are planned for closure over CP5, 383 are due for renewal, and 345 crossings with wig-wag lights will be upgraded to LED lights.
In 2014-15, Network Rail closed a total of 118 crossings, of which 25 were closed using the £74 million of the ring-fenced CP5 funding. This will achieve 21% of the planned 25% risk reduction.
Network Rail plans to close around 250 crossings over CP5 using ring-fenced funding. The remaining funds will be used to commission new technologies at user-worked and footpath crossings.
Infrastructure risks
Says Prosser: “Network Rail MUST continue to better understand its embankments. It has a much better understanding of embankments now, but it needs to follow through with work on civil structures. NR believed it has a good central plan for drainage, but when we went out to the roots we found weaknesses. The plan wasn’t being implemented well – so we took enforcement action.
“That’s why we at ORR have to be on the ball, because if we think NR is not where it should be, we have to act quickly. That’s why it’s important, as a regulator, that we should not be afraid of using our enforcement tools.”
Overview: Some progress was made in improving drainage asset knowledge, and in the stewardship of bridge, tunnel and viaduct civil assets. However, Network Rail needs to do more to manage track geometry and to ensure the long-term safety and sustainability of all its assets.
Drainage: Our inspections found improving main line drainage asset knowledge, but it has been too slow. We found variations in the approach, quality and completeness of different Routes’ drainage management plans, which are needed to address the drainage asset under-investment legacy.
Network Rail must do the necessary work to inspect and maintain its drainage assets. Following on from our work in 2013-14, we served a national improvement notice on Network Rail in February 2015 to drive improvements in drainage capacity and degraded performance, because they increase potential landslip, and therefore train derailment risk.
Track: Network Rail’s current approach is largely based on track renewal and refurbishment work to deliver long-term improvement, and reactive routine maintenance work to correct track geometry faults. It needs to be better and more sustainably managed.
Nationally, we remain unconvinced that Network Rail has done sufficient analysis of the accuracy of its work-banks, to enable us to check that it has sufficient resource (labour, access, material, equipment) to maintain its asset.
However, at this stage we are satisfied that immediate safety risks arising from poor track geometry is being controlled, although in an inefficient and largely reactive way that sometimes does not address the underlying causes of faults and which misses opportunities to address identified weaknesses.
Crucially, further reductions in repeat track twist events are largely dependent on renewal and refurbishment volumes being maintained and supported by more effective maintenance interventions. Keeping the right balance between maintenance and renewal activity will be essential. If renewals are not delivered to plan, it puts increasing pressures on maintenance delivery units to identify and manage defects. Repeated monitoring and repair activity is inherently less reliable than permanent repair.
Switches and crossings: Our November 2014 enforcement on Network Rail demonstrated that while good central review and development of technical solutions supported by clear process is important, equally important is their implementation in the field, supported by suitable mentoring and monitoring activity.
Our future inspections will focus on the potentially increased pressures on maintenance delivery units (as a result of the under-delivery of planned renewals and refurbishment), and shortfalls in mechanised maintenance such as tamping and stone blowing.
Earthworks: Network Rail has refined its contingency arrangements in the event of severe weather, but this is not a sustainable long-term response. There must be an overall improvement in earthwork asset condition. The first step has to be better knowledge of its asset condition.
Structures: There was a growing backlog in structures examinations. Network Rail must halt this trend and ensure it is adequately resourced to inspect the condition of its civils portfolio - the physical features (such as bridges, tunnels and earthworks) on which railways are built.
Off-track and vegetation management: Our inspections found that vegetation conditions and its management varied across routes. Following our interventions over 2011-13, we found that the impact of the leaf fall season in 2014 was now mostly managed consistently, but was off the pace in discrete areas.
Safety by design
Overview: Our work is focused on duty holders’ failures to take opportunities to eliminate or reduce risks at the design stage, especially during new-build and refurbishment projects.
NR’s major infrastructure projects present significant opportunities to eliminate or reduce risks. Some safety enhancement may only be reasonably practicable if implemented at the starting point of an infrastructure’s lifecycle.
We took enforcement on Network Rail in April 2014 because of its failure to have suitable and sufficient assessments of the risks to passengers, public and staff at two Western upgrade sub-projects. And again in January 2015, due to the failure of its North West Electrification Phase 1 project to comply with electrical safety standards, to which it had committed.
Infrastructure worker safety risk
Says Prosser: “Infrastructure and construction work on the main line railway is our biggest concern, but also electrical safety. We’ve seen fatalities that have been avoidable. A major cause has been culture, where risks have been taken with some of these processes.
“NR is slowly bringing in a new set of processes that are simpler and which mean more effective planning. In some cases, a Controller of Site Safety would be given a safe system of work to operate that he hadn’t even been involved in producing. We must get the people doing the work to plan the work. We need to see one person in charge.”
Overview: Overall workforce harm declined by 3%, but when normalised by the 3% decline in workforce hours worked it showed no significant change. Undoubtedly, the big challenge for the industry is culture and behavioural change for infrastructure workers, to help implement planned safety improvement initiatives.
