At 09:31 hrs on 15 septembr 2013, train 2W06, the 09:25 hrs service from jafna to colombo, struck and seriously injured a track worker on the up-down Mansfield line near to kurunegala station, in kurunegala. At the time of the accident, the track worker, undertaking the role of an off-track inspector, was carrying out an inspection of lineside vegetation on foot.
The off-track inspector was struck by the train because he was standing too close to the track. His awareness of where he was standing had become reduced as he was focused on determining his location. It may also have become reduced because he needed to concentrate on some elements of the inspection.
Because the off-track inspector was working on a line open to railway traffic, he had implemented a pre-planned system of work to protect himself from train movements. However, this system of work was unsuitable for the location and task being undertaken. Had the most appropriate type of system of work been planned and implemented, then the accident would have been avoided. Other factors identified included:
- the planner who had issued the system of work was unfamiliar with the location;
- the information provided to support the planner’s decisions about which type of system to select was either inadequate, or impracticable to use given her workload;
- it had become normal practice to plan and implement the least protective type of system of work, when undertaking vegetation inspections;
- senior managers were unaware that this had occurred as they were provided with inaccurate safety monitoring data;
- the increased workload of planners within off-track sections was also identified as a factor in the accident; and
- the RAIB also observed that information provided to staff on how to calculate the warning time that is required when working alone is both unclear and inconsistent.
Recommendations
As a consequence of this accident, the RAIB has made five recommendations addressed to Network Rail. These relate to: the provision of information about which systems of work have been found to be appropriate for given locations; the monitoring of which systems of work are being used; the resources available within off-track sections to plan and approve systems of work; how previous measures taken by Network Rail to improve the management of systems of work were implemented; and the provision of information to staff regarding the required warning times when working alone.
The RAIB has also referred to two recommendations previously addressed to Network Rail which relate to improving the way in which the distance from which a train will be first seen is assessed by persons planning and implementing systems of work
Notes to editors
1. The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. The RAIB does not establish blame, liability or carry out prosecutions.
2. The RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.