We Have Rules For a Reason

It would seem, from early reports, that the safe system of work at Margam was compromised to the point of there not being one.

An initial report said there was “no safe system in place”.

Early investigations found Mr Delbridge, from Kenfig Hill, Bridgend, and Mr Lewis, from nearby North Cornelly, had been using a tool with a petrol engine and wearing ear defenders, meaning they did not hear the train, which was travelling from Swansea to London Paddington.

As I understand it, they were supposed to be working open lines. This means that they had either lookout protection in place or some form of track warning system. Given the itinerant nature of the work, lookouts would make sense.


The Network Rail and Great Western Railway report said the men had been instructed to work on freeing, oiling and retightening bolts by the unofficial person in charge, who was also to act as a lookout.

What the fuck!?! One of the golden rules of lookout protection is that the lookout is exclusively looking out. They do not – ever, under any circumstances – get involved in the work. The Controller of Site Safety is not allowed to take on a lookout role because the lookout must only be looking out for trains.

There was a problem with a bolt, meaning the lookout became involved in the rail work and suggested putting further oil on the bolt, despite being instructed to remain in a position of safety.

I’ve spent long enough training this stuff and had plenty of people pass though my classes to know that Network Rail’s contractors are fully aware that this is absolutely forbidden in all circumstances. So why did Network Rail staff think that it didn’t apply to them?

I’ve seen in reports elsewhere, complaints that lookout protection is inadequate for the 21st Century. Yet the system as set up works perfectly well. Indeed, I like the system as it makes people aware that they are working in a dangerous environment. Constantly working in line blocks creates a false sense of security, which is another risk, so working from time to time on open lines keeps people alert. Also, some jobs require so little time, that it takes more time to complete the bureaucracy of form filling and approval than it does to get in and get on with it. For this, lookouts are ideal. And, the system itself is not what failed here, it was a failure to implement it. And what do they mean by unofficial person in charge. They either had a COSS or they did not and if they did not, why was the work taking place?

“Whether the train lines are open or closed, clear plans, roles and responsibilities are essential and no work should be done on the railway without a safe system of work plan, which is briefed to everyone in the team before they go on to the track to work,” it said.

Precisely. So if that didn’t happen, the problem is not in the safe system, it is in the culture that made it possible to subvert that safe system. Section 2 of the HASAWA covers this under adequate training and supervision. Something failed here.

As I understand it, the families of the deceased are taking civil action against Network Rail. Given the vicarious liability principle, they appear to have a case.


  1. At what point does the employee become responsible for their own safety?

    In most organisations of any size everyone is an employee. The directors may ensure that there are safe working procedures and the management chain ensures that those procedures are known and followed by the staff in their charge but eventually it comes down to the foreman or worker tasked with operating safely. If they don’t work in the way that they have been instructed is that the fault of the ‘organisation’, that anonymous body that ‘ought’ to have done things differently in the light of hindsight?

    Sadly humans aren’t error free and there is a natural desire to ‘get the job done’ and not to be a ‘jobsworth’. At one time I was involved with naval safety and it was quite frustrating to see the navy take a ‘can do attitude’ to problems (great in wartime) rather than report a hazard and get a proper fix in place.

    Sometimes simple changes can make a big difference and make safety almost automatic. Turning railway location cabinets through ninety degrees may take up more space and disrupt the logical arrangement for multiple cabinets but surely it must stop personnel stepping backwards into traffic?

    • There’s a point to be made here. Everyone in that group will have known what the rules are and none of them spoke up? Yet Network Rail has a policy that everyone should speak up if they are not happy with the arrangements. And yet, despite this, they went ahead and worked with a blatantly unsafe system.

      If they don’t work in the way that they have been instructed is that the fault of the ‘organisation’, that anonymous body that ‘ought’ to have done things differently in the light of hindsight?

      Vicarious liability – this has been determined in various legal actions over the years.

Comments are closed.