B266 Network Rail Shared Learning NRL23-03

Organisational learning from a near miss
Issued to: All Network Rail line managers, safety professionals and accredited contractors
Ref: NRL23-03
Date of issue: 26/06/2023
Contact: Paul Young, Business Manager, Operations


At 01:50 on 13th May 2022, a tamper operative arrived at a site access point. After being briefed and signing in with their COSS, the operative walked un-accompanied in the 4-foot of the line under possession towards the tamper that had already started work. CCTV footage shows that as the operative neared the tamper, they stepped into the 6 foot and then moved as if to step into the 4 foot of the adjacent line. The adjacent line was open to traffic at line speed and at that moment, a train passed the operative, causing them to step back. Once the train had passed, the operative stepped back in to the 6 foot to continue approaching the tamper. The incident was not reported in real time by any of the staff nearby nor the train driver, yet the event was clearly very close to being a fatality. The event was reported as a close call at the end of the shift.

Underlying causes

• The COSS became distracted and did not accompany the operative to the worksite.
• The operative was a late substitute to make up a 3 person crew as contracted. However, this newer tamper could be, and was being operated safely with only 2 people.
• The operative was fatigued after being woken by their employer’s on-call, driving from Kent to North Essex.
• The employer’s on-call arrangement didn’t test whether the operative was fit to work.
• Although the operative was briefed at the access point, they were unfamiliar with the location.

Key message

• The COSS / person in charge makes sure any new person joining a group fully understands the limits of SSOW that will
be in place, the operational site and task risks. If there is a distraction ‘Take 5’.

• Staff on-call to carry out a ‘dynamic’ Fatigue Assessment when called out to site. A Fatigue Management Plan should be in place for anyone on-call (Ref NR/L2/OHS/003 mod 5).

• When change occurs, like new equipment, review your risk assessments to check if you still need the same resources. In this case there was an opportunity to de-risk the activity by having fewer people on track.

• The COSS / person in charge can only supervise the safety of their work group if they are present. If a COSS / PIC moves away, the work group needs to be stood down to a position of safety until they return.

If you have any questions, please leave them in the comments section and we will endeavour to get back to you as soon as possible.


File name : Shared-Learning-NRL23-03-Organisational-learning-from-a-near-miss.pdf

B266 nwr shared learning nrl23-03

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