National Rail has issued the following safety advice. 

Issued to: Network Rail line managers, safety professionals and accredited contractors

Ref: NRL20-05

Date of issue: 20/05/2020

Location: Wales and Western

Contact: Suzanne Kay, Capital Delivery Wales and Western


On the 22nd of February 2020 at Manor Park, London a Controller of Site Safety (COSS) and three track staff were redistributing small steel components between two Road Rail Vehicles (RRVs). Overhead line equipment (OLE) staff were standing on the RRV platforms working above the track staff.

The operator of one of the RRV’s needed to reposition his machine so he sounded the horn having confirmed the move could take place with his machine controller (MC).

The RRV moved and trapped the COSS, one of the track workers, between the two RRV’s. Unbeknown to the MCs, the COSS was between the two RRV’s rear bumpers.

Various people on the ground shouted and the RRV operator moved the machine forward which freed the COSS and allowed him to walk to the cess. The COSS attended hospital later. The consequences could have been fatal.

Underlying causes

• The MCs and On-Track Plant Operations Scheme (POS) Representative didn’t authorise the work within the exclusion zone. They were aware of the activity however, they didn’t challenge it;

• The MC did not ensure the area was clear for the RRV movement;

• Redistributing the steel work was being undertaken as an earlier shift had loaded the materials incorrectly;

• The earlier shift did not clearly understand the following shift’s planned works;

• When planning the works the focus was on the main activity of installing the small steel work. The Task Brief did not reference the track staff activities;

• The person in charge (PIC) was also the OLE Construction Manager and, at the time, more focused on the linesmen installing components. He failed to adequately control the ancillary works of redistributing materials.

Key Messages

• Do not enter an exclusion zone unless agreed by the Machine Controller;

• Never put yourself in a position of danger between two machines;

• Machine Controllers must check all areas before authorising movements;

• All task risks, including any supporting works to the main activity, must be considered as part of the planning arrangements;

• The PIC must be fully aware of their responsibilities for on-site safety;

• Work activity requirements should be communicated clearly between shifts to prevent errors and additional activities to correct;

• Focus on empowering everyone on site to take personal responsibility and to look out for and challenge unsafe acts.

*The source of this information is the Safety Bulletins from National Rail and can be found here