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Review and Development of Safe Working Practices in Electrified Areas - Report No. 2
Issue: 1.0 Date: 1st December 2006
T345 - Review and Development of Safe Working Practices in Electrified Areas – Report No. 2
Prepared for Rail Safety and Standards Board
Balfour Beatty Rail Projects Limited Midland House Nelson Street Derby DE1 2SA WWW.bbrail.com
© Copyright 2007 Rail Safety and Standards Board
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Part 1 – Protective Provisions Relating to Electrical Safety and Earthing Network Rail Safety Information Bulletin No IMM/GE/001. Section 3 of this report highlights the standards applicable to the scope of the study and against which the research was conducted. and training in respect of working on electrical equipment. Section 4 of the report sets down the history of the isolation and earthing process and details how it has evolved from pre-World War II to the present day. August 2004 Traction Return Circuit Continuity Bonds BR 12034/16 Railway Electrification 25kV A. The review has identified the problem of over issue of overhead line permits on some major work sites due to bad practice and misinterpretation of the rules. The continued use of long earths in the absence of designated earthing points (DEPs) is a cause for concern and we recommend that a national database of DEPs be progressed in Phase 2 of this project. The continuation of the 29987 User Group is seen as key to continuous improvement in the promotion of safe working practices in electrified areas. which can lead to enhanced safety and efficiency. methodical way to achieve safe working on or adjacent to 25kV overhead line equipment (OLE). standards. such as touch voltages and live line indication.R. and make recommendations for revised standards that will lead to greater safety for workers as well as more effective maintenance possessions. The project aims to review the basis on which practices for isolation and earthing during construction. It also lists other pertinent legislation and documents applicable to rail electrification systems including: Railway Safety Principles and Guidance Part 2. including human factor analysis tasks undertaken in an electrified railway and the risks associated with them. This report (Report No. The project is delivered in the form of two separate reports. It recommends that enhanced communication of rulebook requirements is undertaken in this area. It also discusses some developments of processes. It also looks at issues related to working on functioning electrification systems. Design on B. RSSB has awarded a contract to Balfour Beatty Rail Projects under this programme for the Review and Development of Safe Working Practices in Electrified Areas. Section C Guidance on Electric Traction Systems BS EN 50122-1 1998 Railway Applications – Fixed Installations. 2 Issue 1. The review has concluded that the isolation process presented in RT/E/S/29987 is a well proven. Knowing and understanding where DEPs are not available will allow action plans to be formulated to mitigate this risk in the future. commissioning. and maintenance have evolved. 2) addresses the issues of:: how isolation and earthing practices have evolved incidents where human contact with a live conductor have occurred. and equipment. renewals. Report No. Page 1 of 127 .C.EXECUTIVE SUMMARY The Rail Safety and Standards Board's (RSSB's) Research Programme is responsible for the development and delivery of much of the railway industry’s safety-related research and development.
2 Issue 1. The level and content of electrification training on both PTS and COSS courses is a cause for concern and we recommend that Phase 2 of this project reviews both PTS and COSS course content and with the collaboration of Network Rail and Sentinel produces new slides. Predict the types of human error that could feasibly occur considering the tasks that personnel are required to perform in and around electrified areas. It is felt that benefit could be gained from producing a publication highlighting these hazards to raise awareness/understanding to Controller of Site Safety (COSSs) and Personal Track Safety (PTS) holders. to avoid duplication of effort Review a sample of railway incidents involving electrified equipment to determine why the people involved behaved the way that they did. and that a uniform approach be agreed. We recommend a detailed review of electrical clearances given in these documents by the various stakeholders. Report No. The human factors element of the study set out to achieve the following objectives: Review existing literature to identify any previous work on electrified areas.The review has identified the hazards that exist from 25kV OLE. The importance of identifying all recipients of overhead line permits in pre-planning is covered in clause 4. and assessment tools. In cases where raising part of a vehicle could expose the occupants to the risk of electrocution. recognized that this non-compliance is being addressed by the 29987 User Group. which is written in such a way as to make translation into recommendations relatively simple. it is however. The project recognises the good work already undertaken on the changes to Standards and processes for AC overhead line nominated persons (NP) and authorised persons (AP). including recommendations for the reduction of such behaviours in the future. Research into communications errors during railway maintenance suggests that the primary cause of such errors is the design and usability of communications procedures. There is also best practice guidance available on teamwork within the rail industry. the use of distance markers should be considered. Review of electrical clearances to earth has identified differences in the various publications covering this issue and in particular in the Railway Safety Principles and Guidance Part 2 Section C.16 of this report. This guidance can be used to identify ways of reducing the likelihood of teamwork failures in future. Page 2 of 127 . training plans. Research into distance judgement suggests that even experienced crane operators find it very difficult to judge accurately the clearance from overhead lines. The over issue of permits to COSSs and machine controllers whose work activity does not require an isolation is another area of concern and needs to be addressed in both training and cascade briefing. The review has highlighted non-compliance issues with Module 6 of RT/E/S/29987 in regard to isolation planning. Previous research has provided a great deal of practical information on why people behave (intentionally or unintentionally) in a way that goes against safety procedures.
The object of this exercise was to predict the types of human error that could occur whilst working in AC or DC electrified areas. Page 3 of 127 . Report No. In the majority of cases. applying the rules laid down in either RT/E/S/29987 or GO/RT3091 will result in specific risk assessment of the task and a safe system of work to be developed thereby lowering the risk to a tolerable level. A number of recent innovations in the process of being developed or at a point where a development would enhance safety or efficiency are presented at Section 8. 2 Issue 1. action and memory errors.As part of the human factors input to this project. which delays introduction of good ideas and does not make them visible. although these were also predicted. Most tasks do not provide the opportunity for decision-making errors. a predictive error analysis was conducted using the task-based risk assessments developed by OLE and DC electrification specialists from Balfour Beatty Rail. The predictive analysis of human error conducted to supplement the risk assessment of tasks conducted in electrified areas suggested that the predominant types of error that would be encountered would be perception. Further work should be undertaken in Phase 2 of this project to introduce developments that will offer improvement. It is recommended that this work is reinitiated. Expert opinion suggested that decision-making errors would be more likely in planning and management tasks than in manual tasks. An area of concern in the introduction of innovation or development is the apparent lack of change management culture within the industry. The identification of risks in third rail areas was initiated following the introduction of Issue 3 of GO/RT3091 but this work stalled upon its withdrawal.
..............3 8 DEVELOPMENTS................ 2 Issue 1......1 Report No.....................................Contents EXECUTIVE SUMMARY................. 32 Review of Historical Incident Data ............................................................ 17 Typical residual 25kV hazards ..................4 4..................................................................... 32 Literature Review ................................... 22 Compliance with Isolation Procedures ..... 23 Identification of Overhead Line Permit Recipients .............19 4..............................3 3............................. 25 25kv Electrical Clearances to Members of the Public on Station Platforms ...................22 5 6 CONSIDERATION OF DC THIRD RAIL ISOLATION AND EARTHING PROCESSES . 9 Introduction................................................................ 73 8................................... 22 COSS Electrification Training.............................................................................................. 69 Summary....................................................21 4............................................................7 7 Introduction......................................................................................................................................................................... 9 Other documentation considered ........................................................................................................................2 6..................6 4.....................6 6........................ 8 3..............................................2 4.... 73 TASK IDENTIFICATION AND RISK ANALYSIS .....................................................9 4.................................... 6 BACKGROUND ....... 15 Issue of Overhead Line Permits.............................................. 12 Isolation Process Flowchart ..............................................17 4.........................................................................................10 4............................................................... 21 Hazard and Risk-Based Briefing ....................................................... 32 6......................2 7................................................................ 7 REVIEW OF PERTINENT DOCUMENTATION ...........1 6...................................................................4 4 Railway Group Standards ................................................................... 8 Network Rail Company Standards .................................................................................................................................................................................. 67 7....................................................................................................................................................................................................................................................... 24 Over Issue of Overhead Line Permits...................................... 11 The Isolation & Earthing Process ......... 21 PTS Electrification Training..........................................1 3................................................................................................. 31 HUMAN FACTOR ANALYSIS.... 26 Clearances to Members of the Workforce and Public in EN 50122-1.................... 36 Results of Review of Historical Incident Data ................12 4.................................. 49 Recommendations............................................................................................................ 14 Isolation and Earthing Process – Control Measures ..............16 4.............................................. 9 Legislation .................................... 67 Example of Task Identification and Risk Assessment Process........................20 4............................18 4........................... 28 Electrical Clearances to Earth........15 4........................................................... 30 EVOLUTION OF 25 KV OLE ISOLATION AND EARTHING PROCESSES ..................................... 16 Hazard from 25kV overhead line equipment.8 4................................... 22 Nominated and Authorised Persons Competence................................................................................................7 4....................1 4.......... 29 25kV electrical clearances to earth summarised:........................5 6...........................................2 3........................................................................3 4....1 7......................... 70 Introduction......................................................................................... 23 Alternative Methods of Issuing Overhead Line Permits...................................................................................................... 17 Planning and 25kV Residual Hazards...... 24 The Origin and Purpose of the ‘9 foot rule’ (sic)................................................................... 56 Methodology...............13 4.................................................14 4..............................11 4.......................................... 22 Isolation Planning ........5 4...................... 39 Conclusions....................... 11 4............................................................ Page 4 of 127 ............................................................................................................................................................................................................................3 6......... 1 1 2 3 INTRODUCTION ..4 6...... 53 Predictive Error Analysis........
....... 81 Recommendation 2 – Vertical Slice Audits......3 10...............................Greater Emphasis on Supervisory Checks ..........Live Line Data Loggers................................................18 10... 83 Recommendation 17 – Development ..................................9 10............... 73 CONCLUSIONS ......................................................................19 11 Introduction.......... 82 Recommendation 9 ................................Introduce Safety Communications Training ................. 83 REFERENCES ........................................12 10............ 83 Recommendation 15 – Development .........................................................Live Line Testers ......................................................17 10..13 10...................................................... 78 RECOMMENDATIONS.............................Conductor Rail Gauging................... 81 Recommendation 5 – Electrical Clearances to Earth................................. 82 Recommendation 13 – Tasks on the DC Third Rail................10 10...........................11 10..........6 10......................................................................................................Live Line Indicators........5 10..................................................Incident Reporting........................1 10...........16 10......................... 81 Recommendation 1 – Communications ......................... 82 Recommendation 8 ...........................................................................Safety Observation Schemes ..........2 9 10 Specific Developments .............2 10......14 10..............................................Checking the Planning Process ............................................................. 81 Recommendation 3 – National Database of DEP Locations .................... 83 Recommendation 16 – Development ..15 10......Further Analysis........................... 84 Report No................................ 2 Issue 1.... 81 10.............................. 82 Recommendation 11 .......8......................................................................... 83 Recommendation 18 – Mandated use of PPE in DC Conductor Rail Areas .......................4 10................... Page 5 of 127 ................................................ 82 Recommendation 12 – RIMINI Approach .. 81 Recommendation 4 – PTS and COSS Training......... 81 Recommendation 7 .......... 81 Recommendation 6 .......7 10......................... 82 Recommendation 14 – Development .................... 82 Recommendation 10 ....8 10........................
Report No. renewals. In particular. Page 6 of 127 . it focuses on the voltages that appear on the running rails.1 Introduction The Rail Safety and Standards Board's (RSSB's) Research Programme is responsible for the development and delivery of the railway industry’s safety-related research and development. It also looks at issues related to working on functioning electrification systems. and training in respect of working on electrical equipment. in addition. efficiency without compromise to safety. such as touch voltages and live line indication. including human factors analysis. The study has focussed on 25 kV AC systems because potentials that are high enough to present a safety risk are much more likely to occur. which can lead to enhanced safety and. standards and equipment. RSSB have awarded a contract to Balfour Beatty Rail Projects under this programme for the Review and Development of Safe Working Practices in Electrified Areas. It also considers the influence of the protection system in determining the length of time for which elevated rail voltages may persist during a short circuit. incidents where human contact with a live conductor have occurred. commissioning and maintenance have evolved. It also discusses some developments with processes. The project is delivered in the form of two separate reports. This report (Report No. The project aims to review the basis on which practices for isolation and earthing during construction. tasks undertaken in an electrified railway and the risks associated with them. under a variety of conditions. 1 considers some fundamental electrical issues that impact on safety. 2) addresses the issues of: how isolation and earthing practices have evolved. when compared with DC third rail systems. Report No. 2 Issue 1. and to make recommendations for revised standards that will lead to greater safety for workers as well as more effective maintenance possessions. and on connected non-live conductive structures.
many with little history of railway working and in particular electrification systems Although it is generally recognised that change is effectively managed by the Safety Case requirements and that standards and procedures are amended to reflect the change. concern remains within the industry regarding both workforce and passenger safety. The corporate memory issue is further compounded by the disaggregation brought about by privatisation with no one body holding all the information. Improvements in efficiency in taking isolations and applying earths is seen as key in ensuring the future condition of the rail network as a whole. The disaggregation of the rail industry has resulted in a need for many independent organisations providing discrete services to interface with each other. The move to privatisation resulted in a massive loss of skill and expertise at all levels in the rail industry. requiring higher fault levels Operational changes that have affected the management of both infrastructure and trains Disaggregation of the rail industry into many smaller service providers. Many changes have occurred over recent years. the people who were lost were the people who set the standards that form the basis of what is in place today. including new auto transformer systems. protection devices. The risk of electrocution from contact with an energised conductor remains high.2 Background The electrification system and the associated operating procedures have been designed for safe operation. etc New rolling stock. When these people moved on they took with them the corporate memory which formed the decision making criteria of what was done and why. In many cases. This demands much better controls and communications to be applied to ensure safety for both the workforce and the travelling public. Page 7 of 127 . The desire to achieve increased passenger growth has seen an increase in traffic density. switchgear. with greater power demand Increased traffic density. which include: Infrastructure changes. 2 Issue 1. Report No. although this must be achieved without compromise to safety in taking the isolation or provision of a safe system of work. which in turn limits the availability for access to the infrastructure for maintenance and renewal purposes. and any mitigation of this risk is desirable.
3 Review of Pertinent Documentation There is a plethora of documents which cover the subject matter contained within this research ranging from railway safety principles and guidance produced by the HSE. Defines the requirements for the production of safe systems of work to prevent injury for electrical Persons Working on or near to AC causes to persons working on or near to Network Electrified Lines Rails AC Overhead line equipment that danger may arise.1 Railway Group Standards Title Production & Management of Electrification Isolation Documents Electrified Lines Traction Bonding Safe Working on or Near Electrical Equipment Document no Date/ Issue GL/RT1252 GL/RT1254 GM/RT1040 GI/RT7007 Apr-00/1 Apr-00/1 Aug-96/1 Jun-02/1 Synopsis GI/RT7033 Jun-03/1 GE/RT8024 Oct 2000/1 GE/RT8025 Oct 2001/1 GO/RT3091 Apr 1998/2 GO/RT3093 Dec 1999/2 GO/RT3260 Aug 1998/2 GO/RT3279 GO/RC3560 Dec 1999/5 Aug 1998/1 Defines the requirements for the production & management of isolation documents for all electrified lines Mandates the requirements for electrified lines traction bonding The requirements for providing a safe system of work Defines the requirements for low voltage Low Voltage Electrical installations on Network Rail controlled Installations infrastructure This document mandates the arrangements for the management & specification of lineside operational Lineside Operational Safety Signs safety signs in order to provide consistency of form and presentation throughout the network. and defines requirements Safety Critical Work for systems for managing the competence and fitness of persons required to undertake such work. The standards listed below were used as the basis for this research. 3. other legislative documents. Clarifies the application of the Railways (Safety Critical Work) Regulations to Network Rail Competence Management for controlled infrastructure. Sets out the minimum requirements for high High Visibility Clothing visibility clothing The recommended components of a competence Code of Practice . Railway Group Standards. Network Rail Company Standards and European Standards. The minimum requirements for planning The Planning Requirements for engineering work to ensure the risks to operational Operational Safety of Engineering safety are effectively controlled to be as low as Work reasonably practicable.Competence assessment system to assist compliance with Assessment GO/RT3260 Competence Management for Safety Critical Work Table 1 Railway Group Standards Report No. Mandates the design requirements for the avoidance Electrical Protective Provisions of direct contact between persons and live parts of for Electrified Lines electrification equipment and of electrical equipment on trains These instructions set out the actions to be taken to avoid danger from DC electrified lines or the DC Electrified Lines Instructions process to be followed to determine the actions to be taken to avoid such danger. 2 Issue 1. Page 8 of 127 .
2 Issue 1./SP/ELP/27203 facilities where local isolations are permitted on AC Electrified Lines Specification for the preparation of isolation diagrams and instructions EHQ/SP/S/030 for AC Electrified Lines RT/CE/C/033 Historical Competence requirements for safety critical permanent way work NR/GN/ELP/00004 AC Electrified Lines Earthing and Bonding NR/SP/ELP/24009 Competence requirements for Electrical Control Room Operators Index of Railtrack documents relating to Electromechanical plant RT/E/S/20000 Historical engineering activities Instruction for making out. (historical document) 3.Guidance on Electric Traction Systems BS EN 50122-1 1998 Railway Applications – Fixed Installations. August 2004 Traction Return Circuit Continuity Bonds BR 12034/16 Railway Electrification 25kV a. earthing and indication NR. issuing and cancelling HV Permits to work./SP/ELP/27154 Procedure for the use and care of BR Type Testers Procedure for use of Permaquip Scissors type platform machine and High NR. Routine Inspection and Testing of NR./SP/ELP/27150 Capacity Trolleys as used for OHL Maintenance Maintenance of Mark IIIB Overhead line equipment (formerly NR. Date/Issue Title NR.3 Other documentation considered Railway Safety Principles and Guidance Part 2 Section C .c. Part 1 – Protective Provisions Relating to Electrical Safety and Earthing Network Rail Safety Information Bulletin No IMM/GE/001.R.4 Legislation This section is not an exhaustive review of pertinent legislation. Storage.2 Network Rail Company Standards Document No. Design on B. the Health and Safety at Work etc Act 1974 (HASAW) requires that: Report No. NR/SP/ELP/21067 sanctions to test and circuit state certificates Competence of persons working on or having access to Electrical Power NR/SP/ELP/21070 supply equipment Appointment. As far as employers and employees conduct themselves relating to particular activities in the isolation process.3. rather it picks out the headlines as they influence the people and equipment involved in the isolation process. Page 9 of 127 ./SP/ELP/27171 Rubber Gloves Specification for the provision of isolation./SP/ELP/27214 EHQ/ST/O/003) Procedure for the Issue. Training & Assessment of Persons Working On or having NR/SP/ELP/24001 access to Electrical Power Supply Equipment for Railway Traction NR/SP/ELP/21085 Design of earthing and bonding systems for 25 kV AC electrified lines NR/SP/ELP/21131 Warning and other signs for AC & DC Electrified Lines Working on or about 25kV AC Electrified Lines (formerly NR/SP/ELP /29987 RT/E/S/29987) RT/LS/P/006 Maintenance and contents of the National Hazard Directory EHQ/SP/S/030 Jan 1992 Specification for the preparation of Isolation Diagrams and Instructions NR/WI/ELP/2708 Dec 2004 Instruction for the Layout of Overhead line equipment Table 2 Network Rail Company Standards 3.
It shall be the duty of every employee while at work: To take reasonable care for the health and safety of himself and of other persons who may be affected by his acts or omissions at work. training and supervision. Employers must specify essential requirements and ensure. methods of identifying circuits) shall be available for: Cutting off the supply of electrical energy to any electrical equipment The isolation of any electrical equipment Isolation means the disconnection and separation of electrical equipment from every source of electrical energy in such a way that this disconnection and separation is secure Adequate precautions shall be taken to prevent electrical equipment.’ As far as the system requirements are concerned relating to the isolation activity. experience. knowledge and personal qualities. Page 10 of 127 . and by the provision of necessary information. instruction. the health. the Railways (Safety Critical Work) Regulations 1994 Approved Code of Practice and Guidance states: ‘The HASAW (Health and Safety at Work etc Act 1974) and MHSWR (Management of Health and Safety at Work Regulations 1999) combine to require all employers to ensure that employees are competent to carry out their tasks without risk to the health and safety of themselves and others. that the demands of a task do not exceed the individual’s ability to carry it out without undue risk.‘It shall be the duty of every employer to ensure. ‘Competence’ means that employees must have the necessary skills.’ As far as employers and employees discharge their responsibilities regarding competence within the isolation process. from becoming electrically charged during that work if danger may thereby arise’ Report No. safety and welfare at work of all his/her employees. the Electricity at Work Regulations (1989) require that (abridged extracts): ‘Suitable means (including. and To co-operate with the employer as far is necessary in order for statutory obligations to be met. 2 Issue 1. which has been made dead in order to prevent danger while work is carried out on or near that equipment. where appropriate. so far as is reasonably practicable. through selection criteria for personnel.
an informal title that persists to this day. methodical way to achieve safe working on or adjacent to 25kV overhead line equipment. and the MSW or ‘Woodhead Line’ from Manchester. based on the relatively low number of incidents that have occurred. poster campaign.4 Evolution of 25 kV OLE Isolation and Earthing Processes 4. until the British Railways Board produced BR 29987 ‘Working Instructions for 25 kV AC Electrified Lines’ in 1967. rather than the need to issue numerous (25+) overhead line permits on a current major work site. It is this latter. Page 11 of 127 . and delivery of 25kV AC isolations. This document has been revised numerous times.1 Introduction This section of the report is aimed at people who already have a basic knowledge of 25 kV AC isolation procedures and terminology. now common. cascade briefing to industry through Safety Net or other suitable media. and was re-written into modular format by Railtrack as Company Specification RT/E/S/29987 in 1998. Experience with main line electrification started just before the Second World War with LNER projects to electrify the GE lines between Liverpool Street and Shenfield. the issue of overhead line permits will always take a finite time. Report No. An alternative method of issuing overhead line permits was introduced as an option in RT/E/S/29987 from February 2005. The actions described are well established and universally applied to effect isolation. planning. However they were developed for British Rail maintenance and renewal activities. Over time. enhanced communication to publicise the changes be effected. but it can be as short as thirty minutes if planned and implemented properly. it has proved itself suitable for the task. 2 Issue 1. While the infrastructure and planned isolation involves manual switching and application of portable earths on-site. The isolation process prescribed in RT/E/S/29987 is a well-proven. It is therefore too late to plan and implement an alternative method of issuing permits (which could safely speed up the process). and various documents for individual schemes and regions were produced. This could take the form of industry wide alerts to re-iterate the requirement of the Rulebook. After nationalisation in 1948. The likelihood of this alternative option being selected can be low if: The high number of overhead line permits required is only revealed on the night when the nominated person actually has to issue them. Network Rail continues regular and ongoing review of this document and it remains the electrification document for risk assessment. requirement that stretches the suitability of the standard method of issuing overhead line permits. and general satisfaction with the time taken to issue an overhead line permit. British Rail continued to electrify the network. It is recommended that when changes to the rules occur. Electrification staff know this publication as the ‘Green Book’. The high number of permits that require issuing may be due to the following bad practice: The issue of overhead line permits to every COSS and Machine Controller regardless of whether their work activity requires it (which takes extra time and undermines the value of the permit) These two issues are detailed further on in the text.
and the circuit breakers may be re-closed to energise adjacent part sections that are not part of the isolation. remotely. but if the earth end is applied last or removed first. This is not due to the lack of clarity of the requirement.2 The Isolation & Earthing Process Please refer to the Isolation Process Flowchart in section 4. After operation. 2 Issue 1. Where part-sections are required. they form the point of isolation. The method of earthing OLE was standardised from the mid 1980s by the introduction of designated earthing points (DEPs) with defined earth application points (EAPs). compressing the planning process considerably at the end. the operator will be exposed to whatever voltage is present on the overhead line equipment. In each case a lock or inhibit is applied to prevent unauthorised operation during the period of the isolation. structure mounted overhead line isolators are also operated. Report No. the circuit breakers remain open and form the point-of-isolation. This is due to the associated possession meetings (sometimes referred to as the ‘PICOP’ meeting) occurring in the week immediately preceding the isolation. These enabled short. either manually or at certain locations. It is also by design less susceptible to being removed or damaged by the passage of trains or on-track machines. which are not implemented thoroughly or fall into place later than is ideal: Whilst isolation planning occurs as far out as 40 to 26 weeks before implementation.3 The method of switching off and isolating the traction supply to overhead line equipment is a standard process using remotely controlled circuit breakers to switch off the traction supply. regardless of any irregularity with the isolation. A complete list of overhead line permit recipients should be available to the Nominated Person prior to the isolation being implemented. There are many permutations of this irregularity. the detailed possession planning and submission of the Isolation Details Form (IDF) to the Electrical Control Room occurs in the week preceding the isolation. 4. This can be supplied at the final prepossession meeting or at the latest in the final two days before the isolation. but it remains a frustrating and ongoing omission in some parts of the UK network. The long earth that it superseded for general use relies on operator competence to ensure that the earth end is always applied first and removed last and tied back to prevent collision with trains or on track machines. Many companies and projects have demonstrated that this requirement can be achieved. which in normal use the operator cannot make contact with. pole-applied earths to be applied at high level.It is also recommended that vertical slice audits of the isolation process be undertaken to determine the effectiveness of the Standard and the process. The vertical slice audit should start with GE/RT 8024 compliance including the requirements of RT/E/S/29987. Page 12 of 127 . but one such example is the fatal accident at Ranskill (ECML) in 1998. Where isolation of complete electrical sections is required. There are various parts of the process. but it is often incomplete or omitted to the disadvantage of the Nominated Person. When applied in the correct sequence there is no danger to the operator. rather that the company requiring the Overhead line permits has not identified the total list of named COSSs requiring permits.
A database of DEP locations is very useful in checking and monitoring any corrective action required and to support isolation planning or walkouts.Long earths are still in regular use for certain applications. the installation of DEPs was not completed The EAP may be broken In each case. 2 Issue 1. but should be subject to defined methods of use and control (local management instructions or M&EE COP 1001). and it would be beneficial to gather this information and. a plan of action is required to avoid the continued use of long earths. Page 13 of 127 . turn it into a national database. Report No. using best practice. We recommend that a national database of DEP locations be progressed in Phase 2 of this study. Long earths may be required because: Historically. Some regional information already exists.
2 Issue 1.4. Page 14 of 127 .3 Isolation Process Flowchart Report No.
It is fundamentally a bad practice. The practice of not testing a section of overhead line equipment at all before applying earths. Report No. before the Nominated Person issues individual overhead line permits to each COSS in charge of each workgroup. but it is physically possible (see development section for an improvement to this). EARTHS will be erected at the locations detailed on the IDF. It should be emphasised that this section has examined failures of control measures. Page 15 of 127 . a subsequent inquiry. There is always a set pattern of events after the line has been blocked to electric traction. If there was a switching error (either human error or equipment fault). ISOLATING involves switching. AND a switching error OR applying earths in the wrong location or manner is far from the norm. This irregularity (a live reading on the LLT) would immediately be communicated back to the electrical control room for investigation and the isolation suspended until a deenergised reading was obtained. Short earths applied at DEPs have removed this hazard to the operator. The instant circuit breaker trips thereby creating the potential for danger to life. rather to examine the control measures and consider the hazardous conditions that can arise if they are not applied. or manually switch circuit breakers and isolators to remove all sources of electrical supply. tools and equipment are subject to electrical stress and not a member of staff (it is not completely risk free but the short circuit occurs at high level away from the individual applying the earth as described in the previous section). The following is not intended to describe this process in detail.4. There are two possible results when omitting this control measure: Scenario A: Scenario B: No adverse reaction . and has no place in a well managed and delivered isolation. and apparently de-energised equipment was in fact still energised. Where these incidents do occur this is the most likely conclusion as short earths are in more common use than long earths. The likelihood of an incident increases if any control measures are stripped away. the LIVE-LINE TESTER (LLT) applied to the overhead line equipment (OLE) before the EARTHS were applied would indicate that the line was still energised. There is the greatest potential danger to life within Scenario B if a long earth is used and applied incorrectly. which is: ISOLATE-TEST-EARTH. This relies on the electrical control room operator following written documentation to remotely. to disconnect the section of overhead line from all sources of supply.4 Isolation and Earthing Process – Control Measures The isolation process is robust in that several control measures prevent access to energised equipment. If wrongly applied live end first. a key reason why they were introduced. The circuit breaker tripping would result in the isolation being cancelled or delayed. however. the unsecured earth end at ground level would be live at 25kV. the energised condition of the OLE would not be identified until the application of the EARTH. If the mandated TESTING control measure were omitted. and possible disciplinary action. as described previously. When the live-line tester indicates de-energised overhead line equipment. stripping the testing control measure away is not compliant with procedure or training.the remaining part of the isolation proceeds normally. Scenario A will occur if switching has been carried out correctly removing all electrical supply to the OLE sections and the earths are being applied at the correct locations recorded on the Isolation Detail Form (IDF). This most dangerous situation would only occur if training was ignored. Testing prevents Scenario B occurring by ensuring that these activities are carried out correctly BEFORE the earth is applied. Whilst no adverse reaction has occurred. and leaves no defence against a switching or earth-application point error described next. All NPs and APs are rigorously trained and assessed to apply the earth end first when using long earths.e. wrong side of section insulation or wrong road). Where. 2 Issue 1. Scenario B will result if the electrical supply to the OLE at the earth application point has not been disconnected or the earth is being applied to OLE that is not part of the isolation. The same result would occur if the TESTER were applied to energised OLE outside of the isolated area (i. short earths are being applied at a DEP location.
It is currently considered best practice and is included in the Network Rail NP&AP training package. During 2005. There is a risk of the details and importance being diluted or even lost at this secondary and ongoing transfer. The nominated person must make sure that the COSS understands the following. There is need for time. and by the COSS to his/her work group. use of the STED form became mandatory when it was included in Network Rail Company Standard RT/E/S/29987. and to identify 25 kV residual hazards at least once before any series of isolations in the same area. Where live equipment is adjacent to. 2 A pre-possession site meeting enables the isolation provider to meet a representative(s) of the parties requiring Overhead Line Permits. 1 The Nominated Person should undertake an isolation walkout in daylight hours to check access arrangements. directly affects whether information is absorbed and understood or only a façade of understanding is thrown up by the COSS: o o Whether the COSS includes the permit details in the briefing of his/her work group. they are also recorded on a STED form that serves as a written instruction from the NP to the AP. both by the Nominated Person giving the initial briefing to the COSS. In addition to the Nominated Person (NP) verbally instructing the Authorised Person (AP) of the required manual switching.Several companies have improved the control of these activities with the use of Switching Testing and Earthing Details (STED) forms. or crosses over earthed equipment. section 7 of GE/RT8000: The working limits on the overhead line permit.5 Issue of Overhead Line Permits The briefing and issue of overhead line permits is intended to safeguard the electrical safety of the recipient. times and meeting points and if possible show the COSSs the 25kV residual hazards in daylight hours. 2 Issue 1. extracted from Module AC2. Factors that influence the efficacy of this information transfer include: Maturity of personnel Role specific competence Number of persons being briefed Number of overhead line permits to be issued Speed – driven by time available and operational pressures Thoroughness of pre-work planning: o o o Were the number and recipients of Permits identified in advance? Had an isolation walkout taken place? 1 Had a pre-possession site meeting taken place? 2 Does the COSS understand the briefing that he is given? It is the duty of the Nominated Person to ensure that the COSS fully understands it. earth locations and switching locations. confirm contact details. maturity and professionalism in this process. Whether the relieving COSS is briefed thoroughly and effectively by the COSS he is relieving. The issue of the overhead line permit does not mean that train movements are stopped on the lines concerned. 4. exactly which equipment is live and which is earthed. but the knowledge of the COSS together with the factors above. Report No. testing and earthing activities. Page 16 of 127 .
Each COSS will have an accepted method statement and risk assessment for his work. understanding and compliance with an overhead line permit reduces the risk to an acceptable level. not a residual 25kV hazard. as they are a dayto-day electrical hazard included in PTS/COSS courses. The residual risk from equipment remaining ‘live’ is a factor of the physical arrangement of electrification equipment within. rather than understanding the hazard explicitly and keeping clear of it. and not include the danger from specific residual 25kV hazards. this may be allowed under the rules-of-the-route or may Report No. but the briefing. and the coverage of the planned isolation 4. 2 Issue 1. Expanding on each 25kV residual hazard listed above: 4. but for maintenance work it would be more likely to take advantage of this availability and issue overhead line permits for both roads enabling work on each. regardless of the quality of the overall briefing process. To measure this reliance. Depending on area and line. This is particularly true on sections of two-track railway where rules-of-the-route only allow single road possession and isolation. and the COSS in turn briefing his workgroup.7 Typical residual 25kV hazards Adjacent overhead line equipment remaining alive Section insulators Span wire insulators Back-to-back registration insulators 25kV feeds approaching or crossing over the isolated equipment The live overhead line equipment that abuts the extremities of the isolated area Note: The Nominated Person does not usually include Red Bonds in his brief. These are the hazards that the Nominated Person should brief and make aware to the COSS.1 Adjacent overhead line equipment remaining live In a multi-track area. This fact indicates the particular importance of the Nominated Persons brief. but the need to brief these items depends entirely on whether they are present. The reduction or elimination of residual 25kV hazards is a practical step in reducing the overall risk. being reliant on the work activity of the COSS. The overriding principal to be employed is to remove the person as far as is practicable away from the hazard. Disconnection of Red Bonds and other traction bonding MUST be considered when planning track renewals or modifications in order to maintain the integrity of the OLE earthing.4. This is an important point as it demonstrates safe conditions may appear to be robustly achieved but in reality are much less robust. Page 17 of 127 .6 Hazard from 25kV overhead line equipment The hazard presented by live overhead line equipment is always life threatening and this hazard remains whilst working in an isolated area. Therefore. a practical check would be to ask any individual on-site: • What overhead line equipment adjacent to this isolation is still live at 25kV? Only face-to-face questioning can prove whether the individual has received and retained this information. In multi-track areas it may be possible to work on an outer road and have the adjacent road deenergised only (isolated but no permits issued). That would mean personnel were again working adjacent to a live road. Other tracks may remain energised for operational requirements. It should be stressed that it is possible to work with all roads isolated where this is planned with sufficient notice.7. all roads are not necessarily isolated simultaneously just to allow work on a single road. at some stage work will be carried out with the adjacent road alive. and adjacent to the isolated area. but these documents will generally only consider the basic need for overhead line isolation.
7. 2 Issue 1. one side of the section insulator will be de-energised and the other side will be energised at 25 kV. It is not usually possible to quote an overhead line structure for this crosstrack isolation limit. giving rise to live 25kV equipment approaching isolated area Figure 1 HSSI 25kV residual hazard Back-to-back registrations and span wire insulators are other physical overhead line features that will approach the isolated area in the across track direction that need to be considered within the NP briefing to the COSS.3 Back-to-back registrations Example of back-to-back registration giving rise to live 25kV equipment approaching isolated area Figure 2 Back to back registration 25kV residual hazard Report No. If the job can be planned so that both roads and electrical sections are included then this hazard can be removed but as previously stated. and the COSS briefing his own work group.2 Section Insulators If there is a wired crossover with a section insulator in the isolated area and the adjacent road is not part of the isolation. The nominated person is required to reach a clear understanding with the COSS regarding this residual 25kV hazard.require an abnormal possession and isolation. Example of High Speed Section Insulator (HSSI). Page 18 of 127 . 4. 4. In the latter case significant notice periods have to be given. typically 26 weeks or more.7. this may lead to the introduction of other residual 25kV hazards.
4 Span wire insulators Example of span wire insulation live 25kV equipment adjacent to isolated area (The outer span wire insulators have been moved away from the structure face to the platform edge to remove live equipment from above the platform). It remains a 25kV residual hazard. where each road is a separate electrical section. 2 Issue 1. particularly the area around the transformer bushings and older types of electrification equipment that were not constructed with the above safety considerations. Modern designs ensure that the cross track feed is screened and/or 2.4. Figure 3 Span wire insulator 25kV residual hazard 4. In practice that means a section of overhead line can be isolated and earthed with live 25kV feeds crossing over the top of it.7. Example of live feed able to cross an isolated area giving rise to live 25kV equipment being above and adjacent to the isolated area Figure 4 Live feed crossing isolated area 25kV residual hazard Report No.5 Live feeds crossing the isolated area It is common for structure-mounted transformers to be fed from a different road than that to which the structure is adjacent. Page 19 of 127 .7.75m above the catenary of any separately sectioned OLE. In headspan construction the demarcation provided by the boom or twin track cantilever (TTC) is absent.
As a minimum.4.7.75m typically 50m-75m) that will never be included in the limits of the Overhead Line Permit. there is always an area that is de-energised (minimum 2. both electrical sections are required to be isolated and earthed and an overhead line permit issued. The affect is that an overhead line permit may safely include one road. The isolation instructions are written so that it is never possible to work right up to live equipment in the along track direction. whilst the same along track point on the adjacent road will be live at 25kV and therefore not included in the working limits of Report No. the limits for the adjacent electrical sections should be one span inside the isolated area. A particular along track hazard occurs when adjacent roads are not sectioned at the same point in the along track direction. Page 20 of 127 . in the along track direction. the switching structure is not quoted as the isolation limit it should be one span inside the isolated area in both directions. Figure 5 Insulated overlap isolation limits At a neutral section the isolation limit is not the centre of the neutral section. away from the twin cantilever structures forming the overlap Limit of isolation Insulated overlap Limit of isolation To work in this area.6 Live equipment that abuts the extremities of the isolation At one or both ends of the isolated area. it should be one span inside the isolated area in both directions. live equipment at 25kV will abut. For instance: At a switched insulated overlap. Figure 6 Neutral Section isolation limit At a switching structure with section insulator. live equipment must not approach closer than 2. 2 Issue 1. both electrical sections are required to be isolated and earthed and an overhead line permit issued.75m to the isolation limit structure. and it is possible to quote a different isolation limit for each road. Limit of isolation Neutral Section Limit of isolation To work in this area.
Based on the low number of fatalities or serious injuries to staff due to electrocution this stance has not triggered numerous electrical accidents. rules-of-the-route possessions (and the isolations matched to them) should still be reviewed periodically to assess the residual 25kV hazards. any complacency will modify their perception and reduce awareness of the hazard that equipment remaining live at 25kV represents. A nominated persons briefing for an isolation adjacent to an energised road will have several 25kV residual hazards to brief out.9 Hazard and Risk-Based Briefing The nominated persons briefing should include the electrical hazards present as described in the previous sections. The resultant isolations and 25kV residual hazards are a function of this. There is an associated risk that staff working for extended periods in isolated areas where no residual 25kV hazards are present. regardless of the efficacy of the overall briefing process. but it leaves a disconnection between regular possession planning and the reduction of 25kV hazards. To avoid this dangerous situation it is normal practice to foreshorten the longer isolated section in the isolation instructions so that the isolation limits are the same on both roads. Page 21 of 127 .the permit. including the reduction or elimination of 25kV residual hazards. nor will he generally have visibility of them. will become complacent to that danger. In contrast. and from the COSS to the individuals in his workgroup. but fundamentally. 2 Issue 1. a two-track railway with both roads isolated and no residual 25kV hazards presents few electrical hazards to brief out. It is not standard practice to construct or section the overhead line in this way but instances do occur. The practical way to avoid this disconnection is to have a pre-possession site meeting to understand the proposed work activity and to match the extent of the isolation to it. The standard of the briefing should be of no lesser standard. The reduction or elimination of residual 25kV hazards is a practical step in reducing the overall risk.8 Planning and 25kV Residual Hazards Standard possessions are in accordance with the rules of the plan/rules of the route. but this can be achieved where the limits on the o line permit are several spans within the overall isolated area in all directions. The NP will not have been involved in the preparation of these risk assessments. An obvious but important fact is that the hazard is lower if work is being undertaken in an area completely isolated and earthed. Abnormal possessions should be booked only after considering which overhead line equipment needs to be made safe for the programmed work. The particular risk of any uncontrolled event happening should be covered in each COSS’s risk assessment attached to the method statement or work planning package for any particular work activity. If they move to work in an isolated area where there are numerous residual 25kV hazards present. This should attract the highest standard of briefing and level of understanding reached with the COSS. The Nominated Person will strive to deliver a thorough and effective brief in a professional manner. Notwithstanding that. there is less electrical hazard information to convey. Any lack of uniformity or clarity with adjacent along track limits raises the likelihood of misunderstanding and an injury or fatality to staff. 4. 4. but has no influence on the selection of COSSs who work in his/her isolation. This last condition is rarely reached as there will still be equipment energised at 25kV at one or both ends of the outer track limits of the isolation. rather than the reduction of 25kV hazards being the driving force. This may be a realistic position to take based on train movements being the overriding need. Report No.
Report No. and recertification are then embarked upon. and briefing the overhead line permit. the candidate has to demonstrate that he or she is actually undertaking the duties of a Nominated or Authorised Person by keeping a logbook of completed isolation duties. if satisfactory. Network Rail is in the process of enhancing COSS training in the areas highlighted above. Each audit should start with the isolation request through planning to the issue and understanding of the overhead line permit(s) on site. Licensed trainers deliver universal and comprehensive training material and examinations.11 COSS Electrification Training Any person(s) identified to receive overhead line permits must hold current COSS competence. and peers reinforcing this culture. A review should be undertaken of what the candidates are expected to know compared to the suitability of the training material to convey this. other workers and their supervisors do not tolerate malpractice . An implementation date should be published. This requires complete understanding of the overhead line permit in order to brief the next COSS accurately and confidently. The safety and professional culture of any organisation driven from top-to-bottom affects the actions of the workforce delivering the activity. the whole isolation process should be subject to regular vertical audits across several territories. enables the candidate to achieve full status and work without being accompanied.12 Nominated and Authorised Persons Competence From 2003. followed by a formal mentoring period during which the successful candidate has probationary status only. This is a positive practical step to improving and maintaining the competence of Nominated and Authorised Persons. The assessment process commences with an initial assessment during the probationary period. controlling. refresher training. Individual company training plans with numerous examining and issuing officers appointed regionally by Railtrack or Network Rail have been replaced with one national scheme. In other words. refresher training and recertification training. 2 Issue 1. In order to identify variations with laid down procedure. Experience has shown that the depth and content of the electrification training within the COSS course can be bettered.10 PTS Electrification Training The electrification content in the AC module of personal track safety training should be sufficient to arm the successful candidate with basic knowledge of overhead line terminology and safety.malpractice is eradicated. and must be accompanied whilst undertaking AP or NP duties. Human factors in this equation are looked at elsewhere within this project. There is a risk of the detail and importance being diluted or even lost at this secondary and ongoing transfer. which. Several companies have run local training sessions to reinforce the roles and responsibilities of a COSS when receiving an overhead Line Permit. This has been successfully implemented since 2004 and is subject to regular review. In between assessments. 4. 4. and managers. It has raised the profile of the Isolation activity and the overall quality of training and assessment. particularly in the area of understanding.4. supervisors. This is underpinned by high standards of initial training and assessment. and actual operational practices.13 Compliance with Isolation Procedures Management of workforce competence is connected to minimising the gap between 100% compliance with standards or procedures. 4. All candidates are subject to ongoing assessment. Network Rail and industry wide stakeholder groups overhauled Nominated and Authorised Persons training and assessment completely. Ongoing workplace assessment. This content has been similar for many years. Page 22 of 127 . The COSS is required to include the permit details in his own brief to his workgroup and furthermore each COSS (when and if relieved) is responsible for briefing the relieving COSS.
The key issue is to build on this by identifying the total number and recipients of permits before the isolation is effected.14 Isolation Planning RT/E/S/29987 Module 6 states that the Network Rail isolation planner shall record each overhead line permit requested and allocate each one a unique reference number on an Isolation Planning Form (IPF).15 Alternative Methods of Issuing Overhead Line Permits (RT/E/S/29987 Module 6. Item 05). To ensure compliance with Module 6 it is important that the layout of the IPF and IDF forms are correctly structured to avoid the need for repeated hand written information detailing limits. 2 Issue 1. the summary of which was published in October 2005. structure numbers. if the overhead line function was carrying work out alone. This non-compliance requires the purpose of the IPF to be reviewed. The standard method of issuing permits was not written around that required volume. The requirements of the IPF need to be made clear.8 February 2005 refers) On major railway renewal or project sites. 4. Page 23 of 127 . considering the removal of the IPF as a paper form ready to be re-issued during 2006. Notwithstanding that fact. but still meet the spirit of Module 6. In June 2005. Minor differences to the isolation forms and electrical control room procedures remain but Network Rail is aware of these issues and is positively working towards standardised electrical control room instructions and forms across the network. This is often in the few weeks preceding the isolation (see Appendix A Possession Pack WON 38. electrical sections etc. To ease this demand some individuals explored headroom available in the definition of ‘blockade working’ (pre February 2005 revision of RT/E/S/29987) and only issued an overhead line permit to the Engineering Supervisor (ES). A proforma IPF is printed in Module 6 but as this activity is normally PC based and an ongoing activity. typically within thirty to sixty minutes of the possession being taken. lines. In the final production stage of this document. section 4. and then compliance checked against those clear requirements. The 29987 User Group is re-writing many parts of Module 6. Network Rail established a sub-group of the 29987 User Group to review Module 6 thoroughly. For example instead of allocating a unique reference number to individual permits. The group will have a broad range of personnel involved in the planning and delivery of isolations including the author. That would stop long-term non-compliance with. Current layout suggests that the IPF and IDF are biased towards recording working limits rather than numerous individual permits in any case. including the Isolation Planning and Details Forms (IPF and IDF). more than twenty-five COSSs may require overhead line permits. allocate a reference number to each worksite limits/Form B requested and then the permits identified later to be issued from any one of the Form B’s will share the same reference number. It is worth noting that during the British Rail era (before the creation of the COSS role). 4.Network Rail undertook a national audit of operational isolation procedures for AC & DC electrified lines in 2005. it will probably be customised in some way. this information is typically not identified until much later in the planning process. good progress is being made in this area of isolation planning on parts of the West Coast Main Line (WCML) and the Great Eastern (GE) lines from London Liverpool Street. it is the challenge regularly presented to many overhead line Nominated Persons. it was common that the permit would be Report No. Item 117) or in some cases may not be provided at all (see Appendix B Possession Pack WON 47. It is essential to understand that many of the issues highlighted in this report are current and ongoing. Whilst it may be possible to identify the number of permits required from the outset.
It seriously devalues the permit process as it destroys the link of proper risk assessment of the work activity driving the need for a permit. If actioned correctly. The effect of the Prohibition Notice was to stop the issue of an overhead line permit to the ES only as this was in contravention to the rulebook. the management of the overhead line permit was linked to an electric shock injury and a Prohibition Notice (serial number P/UA/20030702a July 2003) was issued on the construction joint venture alliance comprising Balfour Beatty Rail Projects and Carillion. The electrical safety of all individuals on site must be ensured. Planning was required to be in accordance with Module 6. and enables the NP to establish contact with all the COSSs identified. It is entirely appropriate to plan how twenty-five COSSs and their workgroups will be effectively briefed in half an hour for instance. namely the chance for the Nominated Person to give an effective individual briefing to each COSS. The Nominated Person on the night is then faced with issuing a previously unidentified high number of permits expected in the usual short time to enable work groups to start. If the number of permits is not identified the trigger to consider whether an alternative method of issuing the permits is selected and implemented will be missed. thus eliminating the chance of planning an effective ‘alternative’ method of issuing the permit. 4. Furthermore. 4. The Improvement Notice required that any Network Rail Company Standard specifying safe systems of work at or near 25kV OLE is clear and unambiguous with respect to people’s roles. it ensures that the Nominated Person knows in advance the total number of permits he has to issue. He was generally the supervisor of the overhead line works as well. and be able to be practically implemented on-site. Not identifying all COSS names is a serious omission.issued to the Engineering Supervisor only. At Marston Green on the WCML near Birmingham. rather than hoping the Nominated Person will somehow achieve that on the night. 2 Issue 1. It is for that express reason that the alternative option has been introduced.8.16 Identification of Overhead Line Permit Recipients This topic was introduced in Isolation Planning. Network Rail was issued with an Improvement Notice (serial number 1/0782004 dated 7th June 2004) in connection with the same incident. He should not expect Machine Controller(s) for whom he is responsible to be in Report No.1. they had to meet the requirements of the previous two sentences. Please refer to RT/E/S/29987 Module 6 section 4. or if alternative methods were applied. which contains much useful information on the management and observation of isolation procedures).17 Over Issue of Overhead Line Permits This problem relates to the erroneous issue of permits to either COSSs whose work activity does not require an isolation. or to Machine Controllers who are members of a COSS workgroup and not undertaking the COSS role themselves. then GO/RT4100 (section Z part 1). responsibilities and all arrangements for issuing overhead line permit.8 with respect to alternative methods of issuing overhead line permit. and in the latter case can confuse the responsibility of the COSS to brief his group regarding the contents of the permit. This led to Network Rail introducing Module 6 section 4. the procedure described should be robust to prevent abuse and allow for monitoring to check effectiveness. Something will flex. The early identification of the number of permits is also required to consider whether an alternative method of issuing the permits is selected and implemented. Page 24 of 127 . This was undertaken safely on one particular site in East Anglia (see Her Majesty’s Railway Inspectorates (HMRI) report 220002878/RSC/03-04/5. This does allow for the single issue of an overhead line permit but the planning and implementation of this method is particularly stringent.
’ It should therefore not be considered as an electrical clearance as such. or provided the work is to be performed by specifically authorised staff. provided the work does not require any part of a workman or any tool or materials which he has to use to approach nearer than 9 feet (2.C.1) . the nominated person will hand to each COSS of each work group requiring the isolation. The author has commented on this document and ‘Clearances and screening of live parts. for those that did not need it in the first place.‘…. 4. The selection of this particular distance is now difficult to substantiate but as an example. adding staff that in fact did not require a permit only makes this problem worse! The option of applying an alternative method of issuing the permits is now included in the Feb 05 revision of RT/E/S/29987. regardless of whether they were undertaking COSS duties or were already in a COSS’s workgroup Lack of proper identification of permit recipients either because this activity was missed altogether. the distance of 2.18 The Origin and Purpose of the ‘9 foot rule’ (sic) In recent history. The ‘9 foot rule’ should not be read in isolation as other text describes how this distance may be infringed with other controls applied. unless every Machine Controller/Controller of Site Safety in charge of an affected work group is provided with a separate overhead line permit (Form C) by the Nominated Person as detailed in the Rulebook GO/RT 4100 (section Z part I)’. It will require the number of permit recipients to be identified well in advance and the alternative option deliberately selected and implemented. Report No. the following is an extract from the 1975 version of BR 29987 Working Instructions for A.‘Work on or near overhead line equipment that requires an isolation.75m and 600mm in the UK and has derived them to be 1500mm and 500mm using objective criteria. 2 Issue 1. Page 25 of 127 .possession of a separate permit! In plain terms. any reduction to less than 2. Electrified Lines: ‘Work may also be performed in situations other than those referred to above. whilst remaining compliant. Issuing a high number of permits in a timely fashion severely stretches the ability to use. 7. or not based on risk assessment: both leading to a ‘cover all’ over-issue approach being adopted.75 metres) to the live equipment. it can also render the permit ‘as just another piece of paper’. This was applied by issuing every Machine Controller with a permit. the traditional method of briefing and issuing to individual COSSs. a separate overhead line permit…’ Inexplicably the words ‘requiring the isolation’ appear to be ignored by some readers leaving ‘each COSS’ Confusion with a Machine Controller always requiring COSS competence but not necessarily undertaking COSS duties on any given worksite The Prohibition notice issued to the construction joint venture alliance comprising Balfour Beatty Rail Projects and Carillion (serial number P/UA/20030702a) which prohibited . without reference to the Electric Traction Engineer or equivalent officer. dated April 2005 has considered the dimensions equivalent to 2. but a formulaic distance judged to be a safe working distance to allow a worker to approach live OLE without reference to the local overhead line depot.75m would be difficult to substantiate 3. according to EN 50122-1’ to RSSB separately. Factors that have contributed to this practice include: Misinterpretation of GE/RT 8000 (Module AC2. On this criterion.75 metres or 9 feet has been used as a safe limit of approach towards live OLE without reference to the electrification department. BR 29987 allowed this form of working through the ETE 3 European Standard Technical Report – Annex CLC SC9XC WG 14. The Nominated Person would have to issue more permits than necessary either on a planned basis or in the worst case having to issue permits as required to an unknown number of recipients ‘on the night’.
department assessing all factors and nature of the work, and then prescribing one of three solutions: Specified demarcation line (to work up to) Temporary screening (a rigid barrier) Only work under the protection of an overhead line permit (OLE isolated and earthed) Under no circumstance could work take place within 600mm of live OLE. RT/E/S/29987 Modules 2 and 3 developed this principle further with written method statements and risk assessments required, based on whether work was to take place up to 2.75m, or within 2.75m up to 600mm. Authorisation of the method of working is prescribed in Module 3. The COSS must be in possession of the accepted method statement and risk assessment, understand them and critically enact the mitigation measures described. (Railway Group Standard GE/RT 8024 “Persons Working On or Near to AC Electrified Lines” refers.) Considering the 9 feet dimension in electrification schemes pre-1967, working instructions generally forbade staff to climb higher than the footplate of a steam locomotive. The distance from the footplate (the ‘standing surface’) to the overhead line contact wire (at minimum height) is approximately 9 feet. This standing surface clearance to live 25kV equipment is in EN 50122-1 (see section 4.20 of this report) and in RT/E/S/29987, relating to the unloading of wagons (module 3 section 9). In this latter application, 9 feet is not specifically quoted, rather the maximum height of the wagon floor above rail level (1.4 metres). Adding 2.75 metres (approx 9 feet) to this dimension results in a very close approximation to minimum allowable contact wire height. Thus, the 1.4m dimension appears to have been derived from minimum contact wire height minus 9 feet. Ultimately, 9 feet (2.75 metres) has been and continues to be applied in two different ways. There is no direct link between each application. The application to risk assessment in RT/E/S/29987, derived from the previous BR instructions, is the more widely held understanding of what the 9 feet rule means.
25kv Electrical Clearances to Members of the Public on Station Platforms
This previous section detailed the misconception that it is forbidden for any member of the workforce to approach within 2.75m of live OLE, where in reality they can, with the appropriate control measures. Drawing number CH/EMP/05/001 considers 25kV electrical clearances to members of the public on station platforms. The individual sketches are based on nominal and normal minimum contact wire height (lower contact wire heights exist on certain routes but normal minimum is representative for the UK rail network). There is no special criterion for contact wire height in station platforms. It can be seen that unless passengers stand back from the platform edge as shown in column three, the 2.75m dimension is infringed in each case, perhaps surprisingly so in some of the scenarios shown. In contrast, analysis of electrical injuries to members of the public in 25kV electrified station areas should occur before considering these clearances as unacceptably small.
Report No. 2
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Report No. 2
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Clearances to Members of the Workforce and Public in EN 50122-1
The following extracts from EN 50122-1:1997 section 5, ‘Protective provisions against electric shock in installations for nominal voltages in excess of 1kV a.c/1.5kV DC up to 25kV AC. or DC to earth’ should be related to the previous two sections: Extract 22.214.171.124-Standing surface ‘For standing surfaces, accessible to persons, clearance for touching in a straight line shown in figure 14, shall be provided against direct contact with live parts of an overhead contact line system as well as any live parts on the outside of a vehicle (e.g. current collectors, roof conductors, resistors). The clearances given in the following clauses are minimum values, which shall be maintained at all temperatures and with additional and exceptional line loading. Due to national or regional existing practises, greater clearances or smaller mesh sizes may be prescribed by the relevant railway authority.’ Extract 126.96.36.199-Standing surfaces for working persons ‘The clearances to be observed for persons working nearby energised overhead contact line systems shall be defined in the operational specifications. If operational specifications do not exist, clearances shown in figure 14 or the clearances according to 5.1.3 shall be used.’ As operational specifications do exist in the United Kingdom these would be expected to take precedence. Figure 14 in EN 50122-1 illustrates vertical and horizontal clearances all round the standing surface. Considering the vertical component only, 2.75m is used but rather than the distance from the extremities of the person, tool or material to the extremity of the live OLE, to be maintained unless other control measures are applied, it is the distance from the standing surface to the nearest live OLE. Whilst that distance is maintained therefore, a worker* may safely stand on that surface according to this standard. Figure 7 below illustrates this. It appears to allow a clearance without further control measures, which in the UK may only be allowed after a method statement, and risk assessment has been authorised and applied on-site. The universal application and compliance with RT/E/S/29987 (module 2 and 3) across all UK railway functions should be checked before judging this ostensibly less onerous approach. *It is surprising that the UK special national condition quoted in figure 7 allows the 2.75m dimension to be applied to members of the public in the case stated. Her Majesty’s Railway Inspectorate would not permit any live equipment over a platform surface whether at 2.75m or 3.5m (the standard vertical clearance for members of the public stated in EN 50122-1). Insulation would be inserted so that cantilevers or span wires are at traction earth potential over the platform surface, or the support structure may be sited other than in the station platform. This clause may therefore have been sought in consideration of clearance from members of the public to roof equipment (pantograph horn, bushings or bus-bars), but would not be applied in the UK to live OLE over the platform standing surface. (Please refer again to CH/EMP/05/001.) Nearest live 25kV
* EN 50122-1:1997 Annex G (normative) Special national conditions Clause 188.8.131.52 ‘The dimension of R3.5 mm (sic) clearance in public areas shown in figure 14 shall be amended to R2.75 (sic) minimum for use in the case of future electrification of existing railway lines with restricted infrastructure clearances
920 mm (indicative) 2.75m 1.83m Standing surface
Figure 7 Vertical clearances to accessible live parts up to 25kV (based on EN 50122-1)
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It was found that these levels were governed by the electrical stress between the live end fitting on the equipment support arm and the roof of the bridge or tunnel. Research and development work had also established that where insufficient headroom is available to allow the normal catenary/contact wire arrangement. meant that the minimum headroom could be reduced by 175mm and this significantly reduced the costs of obtaining electrification clearances. These reduced requirements. requiring total headroom above kinematic load gauge at a support point of 680mm’. *International Union of Railways In 1962. to distribute the stress evenly. 4. A key factor in perfecting the twin-contact wire arrangement and so reducing the headroom for 25kV equipment was the development of large resin-bonded glass fibre rods with track resistant surface covering. These “Special reduced clearance” arrangements mean that a total of only 375mm of headroom is required above kinematic load gauge for 25kV equipment. Special reduced clearances are adopted in all cases of exceptional difficulty or expense in obtaining greater headroom’ Report No. together with modifications to the design of the overhead equipment. Page 29 of 127 . following tests and service experience. which provided a flexible and virtually indestructible combined insulator and support for the twin-contact wires. the statutory clearance requirements on BR were revised and reduced clearances of 200mm static and 150mm passing as were introduced for 25kV operation.83 m and 920 mm have been added as an example based on the typical height of a male individual. gave good current collection even with the most restricted clearance arrangement at bridges. the passing clearance from the contact wire to kinematic load gauge was reduced to 125mm. This fitting was re-designed to a semicircular shape.R. a “twin contact wire” arrangement where the catenary is replaced by contact wire and the two contact wires are supported side-by-side.21 Electrical Clearances to Earth Electrical clearances to earth for single-phase 25kV AC OLE are detailed in many separate UK documents including: Railway Safety Principles and Guidance Part 2 section C Railway Group Standard GE/RT 8025 Electrical Protective Provisions for Electrified Lines Network Rail Company Standard NR/SP/ELP/27214 Maintenance of Mark IIIB Overhead line equipment (formerly EHQ/ST/O/003) BR 12034/16 Railway Electrification 25kV AC Design on B. design effort was concentrated on the investigation of possible further reductions in electrical clearance. The objective set was that any improved arrangement must not degrade the surge and 50Hz voltage withstand levels achieved with the existing arrangements.Note: The dimensions of 1. In 1974. The re-design of the fitting has enabled the clearance above the live end fitting of the support assembly to be reduced to 95mm static and 70mm passing. 2 Issue 1. (historical document) The latter document states: ‘British Railways electrical clearances were originally based on the UIC* recommendation and for 25kV were 270mm static clearance and 200mm passing clearance. At the same time. an additional 25mm being allowed for increased uplift of the contact wire at speeds above 60km/h.
25kV electrical clearances to earth summarised:
These clearances are shown in all the documents listed in 4.21, but with some variation, as shown in the tables below: Network Rail Company Standard & BR historical document Category Normal Reduced Special reduced Static 270 mm 200 mm 150 mm+ Passing 200 mm 150 mm* 125 mm*+ Document NR/SP/ELP/27214 BR 12034/16 NR/SP/ELP/27214 BR 12034/16 NR/SP/ELP/27214 BR 12034/16
* A passing clearance of 80 mm applies to brick and masonry overbridges and tunnels between pantograph and bridge only (not between equipment and bridge) and each case is subject to special dispensation by the Department of Transport. + Where stress-graded glass-fibre bridge arms are used, a static clearance of 95 mm and a passing clearance of 70 mm between the insulator live end casting and bridge are allowable, with special dispensation from the Department of Transport. Group Standard Category Enhanced Normal Reduced Special reduced* Static 600 mm or greater 599 - 270 mm 269 -200 mm 150 mm Passing 600 mm or greater 200 mm or greater 199 - 150 mm 149 - 125 mm Document GE/RT8025 GE/RT8025 GE/RT8025 GE/RT8025
*The values for pantograph to masonry and stress-graded arms are not explicitly stated. Railway Safety Principles and Guidance Part 2 Section C Category Normal Special reduced Static 200 mm 150 mm Passing 150 mm 125 mm Document RSP&G ‘C’ RSP&G ‘C’
Only two categories are explicitly stated.
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5 Consideration of DC Third Rail Isolation and Earthing Processes
The original remit and scope of this study was to consider all types of electrification in use on the network of Britain’s railways. However, the situation in respect of isolation and earthing processes on the DC third rail system remains in a state of flux whilst discussion and agreement on the most suitable way forward are resolved between the HMRI, Network Rail, and RSSB. The current standard covering the requirements for isolation and earthing are covered by DC Electrified Lines Instructions GO/RT3091 Issue 2 1998. This standard was developed following the issue of an improvement notice on the then Network South East Division of British Rail by HMRI. In the period from August 1998 to August 2001, much work was done on the production of a new revised document Issue 3. The main differences between Issue 2 and Issue 3 were enhanced requirements to undertake risk assessments of any proposed work in relation to the danger from exposed live parts of electrical equipment. The standard placed an increased emphasis on any work that was likely to come within 300mm of any exposed live parts of the electrical equipment and called for a method statement to be produced by a competent person who must be a member of an organisation holding a valid Safety Case or a valid Contractors Assurance Case. The competent person was required to describe in the method statement how the intended work was to be carried out, without coming into contact with live parts of the electrical equipment. The standard also set down the requirements to submit the method statement for review and acceptance to a competent organisation approved by the Zone Electrification and Plant Engineer (ZEPE). Other principal changes from Issue 2 included: Isolation Agents Temporary Isolations Protective Switch Outs Machine Switch Outs Revised Strapping Arrangements The revised strapping arrangements potentially involved the requirement to fit additional straps and/or straps being placed in close proximity to junctions and incoming supply. Issue 3 of the standard was issued in August 2001 but was withdrawn shortly after issue due to concern from the industry over the increased risk to personnel applying straps from moving vehicles. Much debate has taken place in the intervening period and discussions between HMRI, Network Rail, and RSSB throughout 2006 were aimed at resolving these issues and determining the best way forward. In view of this, it was agreed with RSSB that no further effort would be placed on this aspect of the study.
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6 Human Factor Analysis
This section of the report concentrates on the Human Factors study undertaken as part of the research. It covers the human factor issues and focuses on the human being and their role in electrical safety. 6.1.1 Remit of Human Factors Study
The human factors study set out to achieve the following objectives: Review existing literature to identify any previous work on electrified areas to avoid duplication of effort; Review a sample of railway incidents involving electrified equipment to determine why the people involved behaved the way that they did i.e. intentionally, unintentionally or because of the influence of company safety culture. Prior to gaining access to incident reports, it was anticipated that some time would be available to interview witnesses and persons involved in the incidents to gain a deeper understanding of the behaviours involved. However, due to the volume of information in the reports received and the consequent analysis time required, this was not achieved. It would have been possible to conduct interviews at the expense of the analysis of some of the incidents, but it was considered more important to gather data from as wide a range of sources as possible; Predict the types of human error that could feasibly occur considering the tasks that personnel are required to perform in and around electrified areas.
A trawl of the human factors literature revealed no previous work explicitly directed towards understanding the human factors issues associated with working in electrified areas in the rail industry. However, some papers covered human factors considerations for railway work in general, including trackside or on-track work. By virtue of the fact that the tasks described in these references could be carried out in electrified areas, they are therefore considered applicable to this project. That is not to say that such tasks would be conducted in exactly the same way in electrified areas (for example, personnel may exercise additional caution whilst maintaining rail in a DC electrified area, and the procedures in place will take account of the additional hazards), however the basics of the task would be very similar. The results of the literature review identified work on the following topics that would be applicable to this project: Safety critical rule compliance; Team-working in the railway industry; Communications errors during track maintenance; Judging distances near overhead power lines. Sections 6.2.1, 6.2.2, 6.2.3, and 6.2.4 provide a brief review of each of these pieces of work, along with their implications for the current project. 6.2.1 Safety Critical Rule Compliance
This work, conducted by Greenstreet Berman for RSSB in June 2004 to address the question of why, although the majority of personnel are conscientious with respect to rules and procedures, incidents have occurred through failure to comply with them. The research investigated the factors
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g. Report No. It was clear from the research performed that non-compliance can be an intentional act (i.g.. individuals may not believe that they are able to comply with formal rules.g. Page 33 of 127 . this work covers both intentional and unintentional behaviours that could result in incidents.g. as opposed to understanding the reasons for non-compliance. a participative supervisory style was found to produce greater compliance amongst workers. on the occurrence of signals passed at danger (SPADs). workers were found to differ in terms of their views. the difference between the two approaches is subtle. it was found that the weather and rail conditions can influence whether or not a driver complies with driving rules). and hence encourage individuals to decide to ‘cut corners’). the prevalence of non-compliance in the industry. others believed that SPADs are inevitable.g. such differences could influence the extent to which individuals are likely to attempt to comply with rules). Some believed they can control SPADs. a ‘violation’ of procedure) or unintentional (i. procedures. however. or they may believe that they do not need to comply with certain rules).affecting compliance. It is anticipated that the types of generic corrective actions identified from the previous research into rule compliance will also be applicable to the results of this study.e.e. and giving workers health and safety duties was also found to improve compliance levels)..g. Attitudes and beliefs (e. It will be beneficial to the project to use the generic solutions to specific types of non-compliance when formulating recommendations during the review of previous railway incidents in electrified areas. sanctions & discipline Improving the rules Making compliance easier / making non-compliance more difficult Education Modifying behaviour Involving staff in rule implementation In terms of the implications for the present study. Cognitive factors (e. an error). The research resulted in the development of a toolkit for the classification of non-compliance with procedures and understanding why such non-compliances take place. The study identified the key influences on safety critical rule compliance as: Organisational factors (e. the design of workplaces may provide the opportunity to use equipment in ways that were not intended or may otherwise encourage non-compliance). It also developed a toolkit of practical methods. which fell under the following general headings: Enhancing safety leadership behaviours Setting clear standards Making rule & compliance important Supervising & monitoring Applying rewards. Individual differences (e. The toolkit also provided users with generic solutions to help encourage compliance. motivators include performance pressures and peer pressures). sometimes tasks can be too demanding for an individual. Environmental factors (e. Motivations and behaviour (e. The work under the present project is directed towards understanding the reasons for the behaviour that led to a violation or an error. for example. and guidance that the railway industry can readily use to improve compliance. 2 Issue 1.g. and methods likely to succeed in improving compliance. Workplace design (e.
covering things that individual team members should do as well as things that the organisations should do.2 Team-working in the Railway Industry Gregory Harland Limited conducted a 15-month study for RSSB during 2003 and 2004 to develop best practice team-working guidance for the rail industry. the authors provide an estimate of human error probability (HEP) which is based upon the number of errors observed divided by the number of opportunities for error (based on the total number of times that the relevant task was completed over the course of the period of recording). failure to use the phonetic alphabet in 78% of cases.g. The best practice guidelines are easily translated into recommendations for action in order to address any deficiencies identified. Report No. not using specific terms (e.2. The preliminary guidance for teamworking best practice was subjected to a pilot study using a sample of railway group members. ‘negative’. The study also resulted in the development of a methodology for assessing both teamwork and the organisational support for teamwork to identify any deficiencies at the individual and organisational levels.3 Communications Errors During Track Maintenance Gibson et al (2004) used an analysis of recorded voice communications to identify the number of communications errors occurring during track maintenance activities between PICOP / COSS and the signalman. the study then worked on the identification of measures of team performance and preliminary guidance on best practice for team-working. The results suggested a very high frequency of failures to implement general communications procedures (e. then the best practice guidelines developed under the Gregory Harland study will provide the basis for recommendations for the improvement of team-working. Using these sources of information as the starting point. A pilot trial of the assessment process and guidelines conducted as part of the study found that the process was readily understood by the participants and provided valuable insights into the current state of teamwork and what was needed to improve it. The study resulted in the development of 20 guidelines for team-working best practice.g.g. 2 Issue 1. This study into human factor issues in electrified areas will be focussing on incident reports involving teams of track workers. 6. Page 34 of 127 . If any of these incidents indicate a failure in team-working practices. ‘disregard’) in 100% of cases. The remit of this work was to: Identify areas where teamwork is most critical within the rail industry Determine best practice for teamwork across the rail industry Identify ways of effectively promoting team-working best practice across the rail industry The research work involved studying team-working within the rail industry and identifying important lessons that could be learned from other industries.6. For each specific error reported. prior to being finalised.2. ‘over’. Two types of error were identified: Failure to implement general communications procedures Deviations in information content Each of these error types was sub-divided into a number of specific errors observed during the study (e. ‘omission or failure to use the phonetic alphabet’).
approximately 18 of these related to signallers and drivers not responding to each other’s communication. but the principle is the same). The recommendations from such standards do not provide a great deal of insight into additional means of risk reduction over and above those taken in the UK rail industry. the Rulebook states that all numerals communicated verbally should be spoken singly (e. A number of standards are quoted which provide precautions or operations near overhead power lines. In addition.g.The authors suggest that this high failure rate is at least in part due to personnel needing to deviate from the procedures as depicted in the Rulebook. ANSI standard and the Construction Safety Association of Ontario. Errors of deviation from information content were classified in terms of slips of the tongue. A CIRAS analysis bulletin covering an analysis between June 2000 and February 2002 reports 27 cases of driver-signaller communications failure. Page 35 of 127 . Un-recovered critical slips involving numerical information accounted for only 0. The researchers provide evidence from air traffic-control studies to suggest that this figure is consistent with natural human variability in relation to the communication of numerical information. they are not used. the analysis may yield information that is of benefit to continued RSSB research into communications errors.2. Canada’s recommendations for safe working practices when adjacent to overhead power cables. Their frequency was much lower than deviations from procedure. but without support on how best to do this. and do not apply to telephone communications (e. some of the suggestions could provide the basis for some recommendations on mitigating risks identified because of the reviewed incident reports. 6. However. This information may provide further evidence for the need to review communications procedures. but operators find this difficult and confusing when working with longer numerical strings. ‘one’ ‘two’ ‘zero’ as opposed to ‘one hundred and twenty’). Although this study aims to examine incident reports relating to electrified areas only. for example: Use of independent insulated barriers to prevent physical contact with overhead cables. The Gibson report is relevant to this study in that it is specifically focussed on human errors made during track maintenance tasks. For example. The research by Gibson et al also provides a number of insights into the reasons for noncompliance with communication procedures that could be useful during the investigation of the human factors causes of historical incidents. 2 Issue 1. The National Institute for Occupational Safety and Health estimate that around 15 electrocutions every year are caused by contacts between cranes and overhead power lines (mostly power distribution lines as opposed to railway systems. Report No. The bulletin cites as a common cause of these errors ‘poor procedures’.4% of opportunities for error during the observations. Raise awareness of the fact that in strong winds cables could sway and reduce clearance between the cable and the vehicle.4 Judging Distances Near Overhead Power Lines There are growing concerns in North America about the risks associated with operating cranes adjacent to overhead power lines. the standard terms required in the Rulebook are based upon radio communication. The authors of the reported study state that it would be beneficial to their ongoing research into human error probabilities to examine the occurrence of communication errors that are involved in incident reports. ‘over’ and ‘out’) hence in communications between PICOP or COSS and signaller. Require crane operation at slower than normal speed when under power cables. including OSHA regulations.g.
they were presented with fluorescent markers laid on the ground at a distance from the crane representative of the maximum safe extent of the boom in that location.Raise awareness of the need for caution when moving over uneven ground that could reduce separation between the vehicle and the power line. these recommendations need to cover all possible ways in which an error could occur. as the recommendations are less focussed than those resulting from the analysis of historical incident data. but when reference markers were provided. the analysis is less focussed than the analysis of previous incidents included in this section. The results are intended to provide the reader with an indication of what could occur. 6. 2 Issue 1. these recommendations need to be very high-level. Because the events are predicted. Page 36 of 127 . and because some predicted errors could happen in a number of different ways. They were asked to do this under two conditions: one in which they used no visual aids at all. indicating the types of mitigation that could be implemented to prevent the predicted errors. A number of recommendations have been made due to the predictive analysis. In the second condition. but would need to be put into context to solve specific problems. A group of 16 trained and experienced crane operators were asked to move their crane hook to the edge of the danger zone around an overhead power cable. and not identified through the analysis of actual events. and the various ways in which these events could come about. and simply judged their proximity to the cable. The results of this work will be borne in mind whilst reviewing incident reports to determine whether any of the recommendations listed above could be used to help prevent recurrence of incidents involving cranes or other similar vehicles with extendable apparatus. Report No. This work has been supplemented by a predictive analysis of human error risk conducted using the task-based risk assessment in electrified areas conducted for this project and detailed in section 7 of this report.3 Review of Historical Incident Data This section documents the analysis of 19 incidents involving electrocution or potential electrocution of members of the workforce carrying out work within electrified areas (both conductor rail and overhead line equipment). Imbeau et al (1996) also conducted some research into the judgement of clearance between cranes and overhead power cables. As this study involved crane drivers working at a distance of 3 Metres from the nearest live cable it was deemed that this study was appropriate to the research undertaken on this project. As such. For all of these reasons we have elected to include this analysis as an appendix to the report. The results of the study revealed that operators were unreliable in judging distance without any reference markers. This supplementary exercise of predicting human error aimed to identify all forms of human error that could conceivably occur whilst conducting those tasks represented in the risk assessment. operators were much more precise and reliable in judging the edge of the danger zone.
Recommendations emerging from the historical analysis are more directed towards preventing a specific type of event from occurring again. but whilst such an error would be acknowledged as having contributed to the incident. Report No. electrocution or near misses. These were as follows: Location Paddington. with some description of other causes. In some cases. given the volume of information included in the 19 reports analysed. However. ABC analysis of violations. This would be considered the direct failure in relation to the incident. and so it is this work which forms the main body of this section of the report. rather than the indirect failures. Acton East Adwick Hither Green Dock Junction Doncaster Belmont Yard East Croydon Handsworth Harlow Mill Hemel Hempstead Liverpool Street Marston Green Oakley Ranskill West Croydon Tollerton Hooton Leighton Buzzard Euston Hett Date 21 January 2000 2 August 2000 25 July 1995 10 February 2002 2 December 2001 8 September 2002 5 March 2002 5 May 2002 8 August 2001 7 November 1999 1 July 2003 7 August 2003 19 October 1998 10 October 2001 2 May 2001 5 March 2003 14 June 1985 12 November 1988 14 April 1998 The reports were reviewed using three forms of human factors analysis: human error analysis. many indirect failures are not explicitly described in the incident reports. or at least reducing the impact of the event if it does occur. For example. they tended to have involved both errors and violations. incidents did not include just one type of human failure. The remainder of this section concentrates on the historical analysis of 19 of serious incidents involving electric shock. Additionally. these would not be thoroughly analysed. Each of these forms of analysis is described in Appendix C. 2 Issue 1. Page 37 of 127 . Because of project time and budget limitations. The primary focus is on the immediate cause of the incident. it is also possible that planning errors could have contributed to the incident. there was evidence to suggest that the safety culture of the organisation that employed the worker had some influence on the incident. or a combination of errors. but not in sufficient detail to perform a human factors analysis. and safety culture analysis. an incident may involve a violation on the part of a worker who did not follow the required procedure for checking whether a line was de-energised. In a number of cases. this analysis has had to focus on those human failures directly relating to the incident.The focus of the work reported here was to identify the human factors lessons that could be learned from previous incidents. or a combination of violations.
2.2 Difficulties in Analysis of Historical Data Re-analysing incident reports after the event is often difficult because the analyst is constrained by the information contained within the report. 3. The following sections of this report provide the reader with a synopsis of each incident. which did not provide any information on what actually happened at the time of the accident. which includes recommendations for addressing similar human factors issues in the future. the reports that were available for this study contained little detail. some comprised only a Coroner’s report. decide whether the behaviour was intentional or unintentional. Use the safety culture analysis-tool to determine any possible safety culture influences on the behaviour in question and recommend action as appropriate. 4. there was evidence of failure in the planning process. as the investigations tended to focus on the reasons for the incident itself. ABC analysis or safety culture analysis) and the recommendations resulting from the analysis of the individual incident.e. When the behaviour was unintentional. In cases such as this.3. apply the human error analysis tool to determine the underlying psychological causes and formulate recommendations for preventing recurrence or reducing the impact of future similar errors. Page 38 of 127 . 6. When the behaviour was intentional. 2 Issue 1. and other works management processes that occurred well in advance of the incident itself. From the evidence available. and specify the alternative. where there was plainly insufficient information to conduct an analysis. where possible these problems have been highlighted although it has not been possible to analyse them in any depth. In some cases. safe. This study was no exception. Full transcripts of the human factors analyses conducted for each of the incidents are included at Appendix D. However. In such cases. Review the incident report and identify the behaviours that were exhibited leading up to the incident.3. this was reported as the outcome of the analysis.This report provides details of the analysis for each incident reviewed. there was insufficient evidence to identify specific behaviours involved in the incident. the nature of these failures could rarely be determined. In some cases. Information regarding human factors issues associated with incidents tends to require a high level of detail to be reported in the incident report. this is stated in this section of the report. and occasionally has to base analysis on assumptions made by the original investigators. 6. In several cases.1 Incident Analysis Procedure The procedure followed when analysing each of the incidents was as follows: 1. apply the ABC analysis tool to determine the triggers and consequences for the behaviour. Report No. human error analysis. 5. In such cases. behaviour along with required triggers and consequences. the form of human factors analysis applied (i.
These can be used to introduce negative reinforcement for unsafe behaviours. Page 39 of 127 . Report No. The formal investigation report finds that this incident included a trend of failing to follow the Live-Dead-Live testing procedure. Procedure should include detailed information on what to do. It was also noted that what appears to have been a switching error had occurred that resulted in the line. 6. and therefore both ABC analysis and human error analysis were applied. However. and why to do it – procedures often focus only on what is required. These recommendations are analysed to identify common themes in Section 6.1 Acton East 21st January 2000 Synopsis The nominated person (NP) for the isolation was applying earths to an isolated section at a designated earthing point (DEP) when there was arcing across and the earth blew. followed by a live line. being energised. Engage some of the personnel involved in relaying their experience of what it was actually like. Analysis Recommendations Raise awareness of the existing procedure that ensures that all live line testing equipment is tested using signage and briefings prior to leaving the depot. followed by the dead line. The human factors analysis of this behaviour suggested that it was possible. the incident report states that the investigation into this error was unable to identify how the switch became closed. and the resulting key recommendations are included at Section 6. Apply a label to a prominent position on the live line tester to remind users of the correct procedure. Publicise the results of this incident to illustrate to personnel the potential consequences of not following the correct procedure. Following each synopsis there is a summary of the recommendations resulting from the human factors analysis of that specific incident.6. but the tester was found to have been defective. given the evidence. It was not therefore possible to perform any analysis on this error. knowing why it is required often helps to encourage compliance. a synopsis is provided which summarises the incident and the human factors analyses conducted. which was expected to be de-energised. the switching error would have been detected. that this could have been either intentional or unintentional. In this procedure. This should include an assessment of a person’s ability to train another person (it does not always follow that a person good at doing the job will be good at training someone else to do it).4. The Live-Dead-Live procedure for live line testing had not been applied. the user tests a known live line.5. resulting in arcing and a blown earth.4 Results of Review of Historical Incident Data This section contains a summary of the review of the 19 incidents used in this project. Increase the frequency of routine testing. and explore the reasons why people do not follow the procedures. and that it could have been closed for up to three months prior to the incident without detection.6. 2 Issue 1. For each incident. Provide training to all personnel who will act as on-the-job instructors. The contents of the incident report state that had the Live-Dead-Live procedure been followed. The NP had conducted live line testing to confirm that the power had been isolated prior to applying the earths. Implement a safety observation scheme to provide praise for personnel seen to be consistently working safely to act as positive reinforcement. This allows the user to confirm the different deflections of the needle for live and dead lines. It was later found that a switch that was normally open was in fact closed. indicating that the section was in fact still live.
and when to pay more attention to the procedures. the behaviour of not wearing full PPE. had it been worn may have reduced the severity of the accident. can be analysed. In such cases. Page 40 of 127 . However. A copy of a three-page internal fax. 25 July 1995 Synopsis A track worker fell with his chest across the conductor rail with no protective equipment worn above the waist. Awareness should be raised of the conditions where performance and communications can break down. resulting in a mild electric shock. paying particular attention to new recruits. nothing to be held above head height). the underlying causes were to do with a need to divide attention between a primary task and a similar secondary task. 2 Issue 1. Report No. was used. 6. a worker carried cut branches to an overgrown area and threw one from above his head to get it well into the overgrown area. Taken in conjunction with the ongoing maintenance work. Another high potential risk scenario was introduced when the NP was supervising a trainee. Note that direct exposure to the third rail is not considered intentional. Decision-making training may be appropriate for NP level personnel. research in air traffic control revealed a higher than average number of incidents when experienced air traffic controllers were mentoring a trainee controller. The tip of the branch brushed the tail wire on the OLE. Analysis Recommendations Provide all OLE workers with a safety induction briefing or formal training in the hazards associated with overhead lines. this was clearly an intentional violation.2 Adwick.Instil in workers the importance of checking all information available before coming to a decision. these two factors may have had a significant impact on performance at the time of the incident.3 Hither Green. A formal investigation report was not available for this incident.4. Assuming that the victim was aware of the requirement to wear the vest. 2nd August 2000 Synopsis Whilst cutting back a bush.e. For example. Check the effectiveness of training and mentoring to ensure that workers are going onto the railway line with the necessary information. which contains the internal investigation report (a brief description of the incident and the investigation conclusions and recommendations). hence both ABC analysis and human error analysis were applied. having removed his high-visibility vest and T-shirt and tied the vest around his waist. which. There are a number of examples of historical incidents where this situation has been shown to contribute to poor performance of a primary task. and was therefore analysed using ABC analysis. and the effectiveness of training provided for mentors. but details of the COSS actions are not available to allow any analysis of the associated behaviour. Review of the incident as part of the human factors analysis revealed little in the way of detailed information to make a clear distinction between intentional and unintentional behaviour. The absence of briefing on the electrical hazards associated with the work was also a factor. Provide a rule of thumb to workers to indicate what is a safe distance from the line (i. which was getting close to the return conductor. The deceased was naked above the waist. there was clearly some unintentional activity which led to contact. Use videos to show graphically the consequences of contact with the OLE. 6.4. so the behaviours concerned could not be examined in detail. The result was electrocution. Witnesses were unable to explain the actions of the deceased immediately prior to the accident.
2 Issue 1. 2 December 2001 Synopsis A worker was asked to go and find a tank wagon in the yard. and this is required if people are to feel comfortable intervening. Some of these problems may be addressed through training on intervention.4. There were no injuries. although it is conceivable that the worker made some form of error in judgement regarding climbing onto the tank wagon. Analysis Recommendations Provide training for how to intervene and accept intervention constructively. Analysis Recommendations All similar work to be completed only under T3 conditions – reinforce the right to stop work in the event that COSS believes that safety is compromised.4.Additional factors identified in the incident report involve failures to introduce safe systems of work and insufficient planning. Identify suppliers of more comfortable PPE under all weather conditions and conduct usability trial.managers need to lead by example and not punish the workers if they are unable to complete a job because of safety constraints. Three hours were required to do the job safely. COSS. There would have been a behaviour Report No. Due to the lack of contingency arrangements. The deputy possession manager intervened to stop this activity until the possession/isolation was confirmed. but since they are contributory factors. which was properly labelled. the COSS decided to amend the method statement to allow removal of the scaffold before the possession/isolation was granted.4 Dock Junction. Assess safety culture to identify why people do not intervene and encourage managers. they are not covered in detail in the incident report. the report contains a number of assumptions. The report suggests that there may have been a lack of awareness of electrical hazards due to the deceased not being issued with Section Z of the Rulebook. There were no witnesses to the accident. If one is not already in place. It is by no means certain whether this behaviour of climbing on to the tank wagon was intentional or unintentional. The human factors analysis has proceeded on this assumption. This involves contractors carrying scaffold poles above head height. but the worker had climbed onto the top of the tank wagon and was fatally electrocuted either by contact with or by arcing from the OLE. He found the tank wagon. In both cases. 10 February 2002 Synopsis A gang of sub-contractors was due to dismantle and remove scaffolding from an area in proximity to OLE under T3 protection. 6.5 Doncaster Belmont. Due to the lack of witnesses. Many people have a problem with this. This incident clearly involves a violation of the procedures by the COSS and hence ABC analysis only has been used to analyse it. Priority to be given to safety over productivity . 6. etc to lead by example. The duration of the possession and isolation were shortened such that there would only be 2 hours to complete the job rather than 4 ½ hours. introduce a scheme similar to “Time Out For Safety” – TOFS) which empowers employees to stop work should they feel that there are any threats to safety. there will have been behaviours that could have been further analysed. Page 41 of 127 . which was carrying fuel for the central heating system.
as it encourages workers to behave safely only when there is something in it for them. and should have a copy of the relevant rules and procedures for their personal use. However. Although these are acknowledged as factors that affected this incident. briefings. What is recommended here is a reinforcement of safe behaviour rather than an incentive scheme. resulting in fatal electric shock. involving those involved in unsafe acts in developing a safer way of working. There was no evidence to indicate what the COSS had been doing immediately prior to the accident. detailed analysis has not been possible. The full incident report was not available for review. the fact that a conductor rail shield was not taken to the worksite and that there was no method statement for the job suggests that violations of procedure had occurred. Given the lack of evidence of the COSS’s actions prior to the accident. Teams that perform consistently safely could receive some form of positive feedback that is meaningful to them (for example a monthly prize – a night out for example that they can all partake of as a team) or even just recognition through publicising their successes in a popular company journal. on a notice board that is often used. Introduce a procedure for a situational risk assessment when an individual or team of workers come across a task with which they are not familiar. Page 42 of 127 . The information reviewed appears to come from two different sources. rather than on the undetermined behaviour of the COSS. the COSS made contact with the conductor rail and the running rail. Introduce regular work audits to allow managers to identify and actively discourage unsafe behaviours. and provides a summary of the inquiry and the conclusions and recommendations of the investigation only. 6. Analysis Recommendations All personnel whose work could bring them into an area where live overhead lines are present should be briefed on the dangers of Overhead Line equipment. etc. 2 Issue 1.associated with this failing.6 East Croydon 8 September 2002 Synopsis Whilst fitting plastic tubes around traction current cables with the conductor rail live and the line open to trains. Analysis Recommendations Clarify through procedures. Introducing incentives for meeting safety targets should be discouraged. rather than triggering a change in their beliefs and values relating to safety. and hence an ABC analysis has been conducted on the incident in general. to reinforce safe behaviour. Introduce a safety observation scheme where an NP would tour worksites on a scheduled basis and provide positive feedback for safe performance. but there is insufficient information in the report to analyse this further. Report No. there is insufficient detail in the incident report to analyse these further. that method statements for all tasks that bear the risk of electrocution are a requirement. All personnel who may encounter labelling used on goods wagons of any description to be provided with training on their location and meaning. etc.4. The report also indicated behaviours associated with the short-term rather than long-term planning of work. regardless of how simple the task may appear.
Other relevant factors included the decision to control a risk using ‘briefing by the COSS’ and the inconsistent recording of the isolation limits in the documentation for the work. resulting in an explosion and burns to both men. Introduce procedures to proceed with caution when resistance is encountered when digging. the procedure for Form ‘C’ acceptance and briefing of COSSs should be consistent across organisations working in rail. To account for the fact that this is unlikely to be the case in practice. This should be treated as a site safety induction. on review of the evidence. Analysis Recommendations Provide additional methodical checking of the planning documentation and information passed to the work site regarding location of hazards. but there is insufficient detail in the investigation report to analyse these further. Provide coaching and / or training in how to communicate safety information effectively. to have been the result of an error on the part of the two workers brought about by a number of factors to do with their expectations. The human factors analysis of this accident focuses on the behaviours of the engineering supervisors involved. site briefings should be provided to ensure that local procedures are briefed to any personnel that have not worked on site before. two workers ruptured a 132kv buried cable. appeared to be unintentional.4.8 Harlow Mill. 6. hence human factors analysis was not possible. the reliability of equipment.7 Handsworth. based on the evidence presented.4. until the source of resistance has been identified. one of the men received an electric shock after coming into contact with live OLE. which led to a failure in briefing personnel on the safety aspects of the work. Report No. Both factors will have involved a human failure or failures. A human error analysis was conducted. and the efficiency of the planning process. and chain of command all contributed to the incident. and having conducted a CAT scan which indicated the presence of a buried metal object. lack of resource. The formal incident report acknowledges several factors relating to planning of the job. and hence human error analysis has been used to analyse this incident. and how to reduce the associated risks – this may involve using a checklist. 5 May 2002 Synopsis Two members of staff involved in the renewal of sleepers and ballast were asked to redistribute the loads in three wagons of spoil. 2 Issue 1. Introduce a procedure that requires systematic checks to be made of the limits of all work areas prior to briefing other personnel. Analysis Recommendations Conduct regular audits of COSS briefings to determine their quality and provide coaching and development for those that require it. This accident seems. All of these will have had behaviours associated with them. which is reported below. Two behaviours were identified which. Page 43 of 127 . but they are not investigated in-depth in the report. Ideally. The two men climbed into the wagons to redistribute the loads. Provide guidance on high-risk handovers. if this is appropriate. sub-contractor safety assessment. 5 March 2002 Synopsis Whilst erecting fencing in the West Midlands and Chilterns area.6. and on reaching the second wagon.
9 Hemel Hempstead. Report No. lack of a method statement and failure to cover electrical hazards fully in the work procedure. determine the potential benefits of conducting line testing procedures whenever moving to a new piece of overhead equipment. It is also clear that some form of human behaviour was also associated with the lack of formal training. error analyses have been conducted for both possibilities. It is also possible that an error was made on the part of the person briefing the victim on his tasks. although these are highlighted as contributory factors in the incident report. ablaze. The formal investigation report identifies a number of factors that were not investigated in detail which relate to a failure to follow briefing procedures and differing isolation and possession limits. 2 Issue 1. However. providing workers with guidance and practice on how to convey safety-related information most effectively in the least ambiguous manner.10 Liverpool Street. 6. The victim was attempting to clean a section insulator rod when he received an electric shock. and workers were warned of this being live equipment. Page 44 of 127 . When work is conducted in an area where the complexity of the overhead lines is high. which includes a recommendation to improve the usability of existing communications procedures to improve compliance levels. As these are raised as ‘factors for consideration’. onto the train roof. hence. The review of the incident suggested that the victim did not intentionally reach out for a live piece of equipment. there is insufficient detail to perform human factors analysis on the associated behaviours. A crossover section insulator was close to the train. suggesting that this was an error. and that at least one other member of the crew did not know that the section insulator in question was live. The COSS did not receive face-to-face communication regarding the job.Indications in this report that there may have been multiple violations on site in failing to follow the procedure to formally brief on the Form ‘C’ contents to COSSs. a contractor made contact with the overhead line equipment.4. 6.4. It was later stated that no one had asked the victim to clean the section insulator. This resulted in the contractor being thrown backwards onto the track and sustaining injuries due to electric shock and the fall onto the tracks. 8th August 2001 Synopsis A group of workers were performing overhead line maintenance from the top of an overhead line train. and to encourage workers on the receiving end of information to check their understanding and clarify any issues they are not 100% comfortable with. but was briefed over the telephone regarding the track arrangements. there is insufficient detail for more detailed analysis of the associated behaviours. and did not gain sufficient understanding of the isolation arrangements from the NP. 7th November 1999 Synopsis Whilst climbing scaffolding at Liverpool Street Station in order to dismantle it. He was thrown backwards. See also the recommendations made by Gibson et al (2004) on reducing safety communications errors. but insufficient evidence to pursue. Analysis Recommendations Provide safety communications training to personnel. and has been analysed using the human error analysis tool. The human factors review of this incident suggested that the contractors involved might have made an error based upon the manner and content of information provided to them regarding the job. This was seen primarily as a planning and control of contract issue.
6. Analysis Recommendations Procedure to state that baskets. Some workers reported they were not sure whether they were authorised to start groundwork on arrival (some were instructed to do so by supervisors). repositioning displaced pots. Shortly afterwards the lookout made contact with the conductor rail. or other exterior elevated structures on vehicles. Provide handover and safety communications training to all personnel working in electrified areas to cover principles of accurate and safe communication.11 Marston Green. not that it is expected – either the permit is in force or it is not. a flashover occurred and both men in the basket jumped out of the basket. 2 Issue 1. The version of the report reviewed was a draft produced on 18 July 2003.e. and hence an ABC analysis was done. 7 August 2003 Synopsis While a gang was replacing broken insulator pots. Include in training the importance of use of positive statements in providing information – i. These were the shortening of the isolation limits prior to start of work. Audits by site safety authority on regular basis to identify problems with briefings or the physical conduct of work 6. but some men did not know whether to begin ground-level work under OLE or stay in the cab. including two-way checking of understanding. An ABC analysis has. will not be used under live OLE. there was insufficient detail in the report to do so. A review of the incident suggested that there was some form of violation on behalf of the lookout engaging in work other than the duties assigned to him. A human factors review of the incident report suggested that the vehicle was driven down the line whilst the line was still live. Several other issues were highlighted in the report associated with behaviours prior to the incident. Situation not clear.4. and a safety culture analysis has also been Report No. with a possible extension to this procedure to leave interlock keys for basket operation with an NP or a person who will not be working under OLE and to have them handed back when the Form C is issued. when it was necessary to raise the basket slightly to see over the cab. and poor briefing from the COSS. 1st July 2003 Synopsis Overhead line prep work was underway at the accident location. One vehicle was set up for control from the basket. documentation references being outdated.12 Oakley. and changing pot fixings. poorly written procedures. There was also some evidence to suggest that the safety culture of the organisation could have had an impact on the behaviour of the individual. The COSSs had briefed the workers that the overhead lines were not yet isolated and that the Form C had not been received. The isolation was delayed. state whether or not Form C is present. indicating an intentional behaviour on the part of the crew. a lookout on the job was seen to bend down as if to do some work. Road rail vehicles (RRV) were driven onto the road rail access point (RRAP) under live OLE to await the Form C. Page 45 of 127 .4. etc. etc. been conducted. not a formal investigation report. Although there will have been specific behaviours associated with these events that could have been subjected to human factors analysis. resulting in a fatal electric shock. therefore. At some point shortly thereafter.Analysis Recommendations Worksite and isolation limits to coincide to reduce the risk of confusion. led to assumptions being made.
or draw them away from other duties. do not rely on implication. and these should be included in the risk assessment procedure. Management to make their expectations clear regarding the quality of risk assessments. while disconnecting local earths from an overhead line structure towards the end of an isolation. 19 October 1998 Synopsis At about 04:50 on the day of the accident. there is insufficient information in the report to analyse these in any more detail. Analysis Recommendations Introduce a procedure. It was also noted that a lack of formal training.4. However. although these are acknowledged in the incident report. Explicitly state in procedures when a particular method of conducting work is not permitted under company policy. • • 6. The workers were trained in the use of long earths.13 Ranskill. Work without an adequate risk assessment along these lines should not be allowed. checking for possessions only one week ahead. i. and the absence of a formal audit and inspection system to observe the isolation process were cited as potential underlying causes of this incident. Long earths had to be used instead of short earths because the expected DEP was not present at the expected structure. Workforce should receive training on effective communication and co-ordination strategies for safety-related activities. Assess the safety culture of the organisation to determine the impact on safety practices within the workforce. rather than those specific to the job. Report No. ensure that practical experience is received within one month of initial training. The lack of a control measure to prevent the possibility of a person applying or removing earths in the wrong sequence. Provide negative feedback if T3 possessions were available but not used due to perceived time pressure. On-the-job training should be conducted either by COSS or by another member of the gang not involved in other duties that could detract from the quality of training provided. 2 Issue 1. and an inadequate method statement were also factors for which there would be a corresponding human behaviour. Analysis Recommendations Conduct regular audits of risk assessments to identify those that focus on high-level risks or hazards. Work planning for electrical work to identify first available T3 possession – planners to be encouraged to look further ahead. a linesman received a fatal electric shock because he disconnected the earth end before the line end was clear. Use a sign-off system similar to the safety briefing to record who provided the training and the confirmation from the trainee that the training has been received. but experience of actually applying them was limited. which states that when removing long earths.e. Page 46 of 127 . A human factors review of the incident suggests that the most plausible explanation for this behaviour was that it was unintended. one man removes both the line end and the rail end of the earth. and hence a human error analysis has been applied.completed. If issues are identified. For safety-related tasks. which need not be in the same format as the original training. See also Gibson et al (2004) recommendations on modification of procedures for safety communication. However. which require their attention. If the task is not performed for an extended period of time (for example 6 months) then refresher training should be provided. there is insufficient detail to analyse them further. develop improvement actions to enhance safety culture with the involvement of the workforce. It seems that communication on who was doing which part of the task broke down in this case.
4. The formal incident report identifies a number of underlying causes. and the HIAB fouled the OLE.The worker who died had worked 21 consecutive shifts. with two 84-hour weeks immediately prior to the incident. however. but there is insufficient detail in the report to analyse them further. 6. Working hours should be monitored and action taken when an individual worker has exposed themselves to high levels of fatigue that could endanger themselves and their co-workers. Where T3 isolation is not possible. Page 47 of 127 . that the use of uninsulated tools could be considered a violation. and injure two workers. which would have prevented the accident. and hence an ABC analysis was conducted. although there was insufficient information in the report to allow full analysis of this. many of which involve unsafe behaviour on the part of management. conductor rail shields must be used as a matter of course. 10 October 2001 Synopsis During the course of maintaining a rail flange lubricator.4.15 Tollerton. They were: Not providing suitable tools Lack of suitable training in risk identification Failure to enforce procurement policy Conductor rail shield applied incorrectly Failure to obtain method statements and risk assessments Failing to monitor contractors All of these factors involved human behaviour. a group of contract staff were to unload track from a HIAB crane. 6.14 West Croydon. A human factors review of the accident suggested that the crane operator had intentionally raised the crane arm. Recommend that where possible. This resulted in an arc that caused the grease in the vicinity to ignite. Human factors review of the incident suggested that this behaviour was unintentional. The formal incident report states that inadequate planning and resourcing of the job was an underlying factor in the incident. Frequent auditing of records should be used to identify problem cases. 2 May 2001 Synopsis As part of maintenance work in the area. resulting in electric shock to some of the men on board. all of which involve human behaviours. It is recognised. precluding more detailed human factors analysis. Analysis Recommendations The work was carried out without an isolation. It seems highly likely that this contributed to his performance on the day of the accident. Report No. The area for unloading the crane was under live OLE. an uninsulated. 2 Issue 1. open-ended spanner contacted the energised conductor rail. electrical work is conducted under T3 isolation Ensure that properly insulated tools are used in electrified areas. but details of the behaviours of those involved in these activities were not included in the report. it was difficult to conceive why someone would do this intentionally and hence human error analysis was conducted.
which lacked sufficient detail to analyse the behaviours involved.17 Leighton Buzzard 14 June 1985 Insufficient information was available on what the victim was doing at the time of the accident to conduct any detailed analysis.4. Information on this incident came from a copy of the post-mortem examination and a typed transcript of the inquest. takes place wherever possible under T3 possession. then these recommendations would also be pertinent (See Imbeau et al. 5 March 2000 Insufficient information on the actions of the injured party was available for the conduct of human factors analysis. however. who was in hospital at the time of the inquiry.Analysis Recommendations Conduct regular audits of work planning to ensure that work. None of his co-workers saw what happened. it would be useful to have had access to more detailed information to determine whether there was also an error involved. The worker took a shortcut that meant that the metal pole he was carrying made contact with OLE. It is therefore not possible to complete a human factors analysis on this incident.4. as the only witness was the injured party. If an error in judgement was involved. 12 November 1988 The worker did not appear to have been briefed of the hazards associated with trains or overhead lines prior to starting work.19 Hett.4. was not an OLE operator. 6. involving vehicles with extending parts. Page 48 of 127 . The lack of clarity is because only information contained in the original incident recording forms and SMIS was available. and work did not seem to have been monitored. then the other with the chainsaw in order to cut through it. Report No. 14 April 1998 There is no evidence in the report to indicate how this incident happened. 6. 1996). when the vehicle is beneath live OLE. The deceased was working at the station for the first time. as it is stated that no interview had been achieved prior to publication of the report. Witnesses stated that the saw sounded as if it was labouring. Note: In the formal incident report there is no transcript of an interview with the crane driver. Introduce procedure disallowing any movement of crane arms. and should have received a comprehensive briefing. 6. 2 Issue 1. providing little in the way of detail on the behaviour of the deceased or others within the organisation.16 Hooton.18 Euston. It was not clear whether the behaviour was intentional or unintentional. It is possible the incident could have been prevented if the saw was capable of cutting through the branch without having to change position and bend the branch to remove it. etc. Previous work reviewed during this project suggests possible simple systems to help improve the judgement of distance when operating cranes near overhead power cables. 6. Information for this incident came not from a formal incident report.4. but from a copy of the inquest along with hand-written and typed witness statements. It is known that the branch that was being cut made contact with OLE because the worker had to cut from one side. The evidence in the report as it stands suggests a violation. This suggests inappropriate tools and equipment to do the job. but that the deceased had stated that it was always like that.
In many cases due to the individual dying because of the incident. there were a number of causes. which were common to many of the behaviours that contributed to. risk assessment or procedure for the job Lack of suitable tools and equipment to do the job (including lack of interlocks. 2 Issue 1. as described in the table below: No. poor lighting) to the psychological (e. seeking approval from a manager or colleague). or ineffective awareness training) Insufficient briefing (includes not following prescribed briefing procedure) Complacency (for example during longterm non-standard activities such as maintenance or when workers are highly experienced with a task) Working under perceived time pressure. Some incidents involved more than one unsafe behaviour that was the subject of the human factors analyses. Page 49 of 127 . one can never be positive about the level of intent involved. 6. leading to the perceived need to get the job done quickly Seeking approval for getting the job done. However. ranging from the physical (e. or seeking to avoid ridicule for not joining in with custom and practice Lack of (or accessibility of) a specific method statement.6.5. Report No. or triggered these accidents. poor ergonomic design) Associated Recommendation Safety Communications Training Supervisory Checks Safety Communications Training Safety Communications Training Safety Observation Scheme Checking the Planning Process Supervisory Checks Safety Observation Scheme Safety Culture Supervisory Checks Safety Observation Scheme Supervisory Checks Safety Observation Scheme 5 5 4 4 These common causes should be used to raise awareness within the organisations working on the railways of the conditions and situations under which the risk of a human failure could be increased. The number of intentional behaviours (violations) and the number of unintentional behaviours (errors) were approximately equal with a few more errors identified than violations. not the number of incidents. and provides some indications as to those that are likely to have the greatest effect in improving safe working 4 This is the number of behaviours identified during the incident review and analysis.5 Conclusions The review of incident reports identified a range of behaviours involved in a sample of incidents spanning the last 15 years.g.g. The following section provides details of the recommendations that were generated because of the analyses in order to combat the common causes in the preceding table.1 Common Causes of Behaviours The review and analysis of the incidents revealed a wide range of causes for the behaviours that were exhibited. of Behaviours Exhibiting Factor 4 9 8 7 Common Cause Poor risk awareness (including lack of awareness training.
a table was created showing all of the incidents reviewed along the top.practices in electrified areas. Page 50 of 127 . the recommendations down the side. these have been merged into a single recommendation that would be applicable to the incidents reviewed. others were applicable to several of the incidents reviewed. Some recommendations were very specific to one incident. the descriptions of the recommendations have been summarised – for details of the recommendations for each incident please refer to the relevant part of the previous section of this report.2 Summary of All Analyses In coming to conclusions regarding the incidents reviewed. Report No. To track this process. the first stage was to consolidate the number of recommendations made for all of the incidents into a more manageable list. 2 Issue 1. The links between the recommendations and the common causes are indicated in the above table. and tick marks indicating which recommendations were applicable to which incidents.5. Where the latter was the case. In the table. 6. The recommendations have been listed in descending order of the number of incidents to which they apply.
scheduled for T3. Procedures to discourage extending parts under OHLE use of vehicle Attach procedural aide mémoire to equipment Rules of thumb for distance judgement Audit training improvements effectiveness and identify Identify more comfortable PPE for all conditions Introduce a Time-Out For Safety scheme Managers to demonstrate safety more important than productivity Report No. Page 51 of 127 Hett . More methodical checks of planning process. etc. audit briefings. etc. Training and procedures for on-the-job trainers Safety inductions that cover generic issues plus dangers of electrical equipment Assess Safety Culture (as required by RGSP). 2 Issue 1. briefings.Dock Junction Doncaster Belmont East Croydon Hither Green Harlow Mill Handsworth Hemel Hempstead Liverpool Street Marston Green Oakley West Croydon Tollerton Ranskill Adwick Hooton Acton Recommendation Leighton Buzzard Euston Safety communication training to include handovers and how to intervene effectively Safety observation scheme to praise safe behaviour and discourage unsafe behaviour. limits of isolation Monitor line testing procedures Publicise incident consequences using videos.
not implicit Procedure for earth removal Provide opportunity for practice following training Monitor working hours. 2 Issue 1.Dock Junction Doncaster Belmont East Croydon Hither Green Harlow Mill Handsworth Hemel Hempstead Liverpool Street Marston Green Oakley West Croydon Tollerton Ranskill Adwick Hooton Acton Recommendation Leighton Buzzard Euston Introduce situational RA procedure Make staff aware of goods labelling and location Emphasise requirement for method statements for all jobs Procedure for verifying CAT scan Consistency of Form C acceptance procedure between organisations Formal audit or risk assessments All procedures to be explicit. Page 52 of 127 Hett . Provide properly isolated tools Rail shield always used when rail live. Report No.
It would highlight situations where workers seek the approval of colleagues and managers. it is felt that further analyses of the incident reports to find out how effective they have been in reducing the occurrence of incidents in electrified areas is undertaken. risk assessment. and allow managers and supervisors to re-define their expectations. The second is to engage the individual in coming up with a better way of doing that task. greater emphasis on supervisory checks. this recommendation would help to identify situations where perceived time pressure is a particular influence. safety communication training and more methodical checks of the planning process are the four interventions that would prove most fruitful in reducing incidents. allowing the setting of more helpful expectations and examples.6. However. it could provide the opportunity to identify cases where workers are required to implement makeshift adaptations to equipment due to a lack of suitability of the original equipment.6. 6.e. the concept is to sit down with the individual and get them to: (a) (b) (c) (d) explain what they did explain why they did it describe what the consequences could have been (what’s the worst that could happen) come up with the suggestions for how to do the same job more safely the next time. It would also identify situations where personnel work unsafely due to lack of a formal method statement. We recommend that the concept of Safety Observation Schemes be further researched under Phase 2 of this Project. this should not be seen as a replacement to sound human factors engineering involvement in the procurement and design of equipment to ensure suitability and usability. The information presented in the Formal Inquiry Reports lacked in detail and consistency. This process has two objectives – the first is to provide positive feedback on the desired behaviour to reinforce that behaviour. and allow workers and supervisors the opportunity to define solutions for such cases. 2 Issue 1 Page 53 of 127 . The idea is that workers get to know that behaving safely brings recognition and will therefore tend to join in. The use of this concept in many organizations has seen an improvement in safety Report No. Benefits In terms of the common causes identified in the previous section. should not prevent the promotion of what is seen as a valuable tool in improving safety awareness. it would seem that safety observation schemes. The introduction of schemes of this nature will not be easy in today’s disaggregated railway. They revolve around management or employee observations of work areas to identify both safe and unsafe behaviours taking place. Finally. or procedure. The aim should be to get the individual committed to doing the job more safely next time. and for the workers themselves to highlight any problems. rather than punishing the individual. When an undesired behaviour is observed. The concept then is to provide positive reinforcement for the desired (i. In addition. this however. From what was found out about the sample of incidents reviewed.1 Implement Safety Observation Schemes Safety observation schemes are designed to aid behavioural change by using the principles of providing feedback to reinforce the required behaviours. to gain their buy-in and commitment to change. safe) behaviour whenever it is observed.6 Recommendations Summarising the recommendations from all analyses in this way provides an indication of the human factors interventions that have the potential to have the greatest impact on incidents involving contact with a live conductor.
A number of principles to do with giving a good handover are applicable to safety communications in general. even though it was not a safe way of doing so. A great deal of work has been conducted in the recent past to develop guidelines for workers on how best to communicate safety information to make sure that the relevant information is correctly understood. Safety communication training should not be classroom-based. the evidence emanating from a number of the formal investigation reports seemed to suggest that the frequency of supervisory checks of worksites tended to be very low.2 Greater Emphasis on Supervisory Checks Related to the previous recommendation. “The lever is not in the correct position” because if the middle part of that message were drowned out by noise the recipient might think that the lever was in the correct position. It would also be possible for supervisors to demonstrate commitment to getting the job done safely. supervisors would be able to check that suitable method statements and risk assessments were in place and would be in a position to make sure that workers were sufficiently aware of the risks to which they would be exposed. Summarise the main points of the communication at the beginning. More checks by supervisors would also have the effect of helping to set management expectations in terms of safety and getting the job done.6. Organisations could be encouraged to do this by inclusions in The Railway Group Safety Plan (RGSP) and through acceptance of Contractor’s Assurance Cases. This would help to reduce the number of instances where workers behave unsafely because they think they will get some from of reward for getting the job done. Report No. do not say. Check that the other person has fully understood.e. Summarise main points at the end of the communication. These include: Communicating face-to-face whenever possible Using positive statements relating to safety issues (i. For example. but also helps to raise the level of visibility of the supervisors.3 Introduce Safety Communications Training A number of incidents seemed to involve incomplete or ambiguous information being passed between team members. supplement verbal information with written or another form of visual information so that there is redundancy of information to help avoid mistakes. Do say. not just nodding their head.performance. it should provide delegates with the opportunity to practice these skills and go away a better communicator. which should be used to check that work is being done according to plan and the prescribed procedures. and that when they did occur they were not very thorough. 6. 6. “The lever is in the wrong position”). Where possible. and hence help to avoid workers gaining the impression that they are under time pressure. do not take it for granted. Person you are communicating with should be actively listening. Benefits Several of the common causes identified in the previous section would benefit from improved supervisory practices. asking questions and confirming understanding.6. Organisations should be required to place a greater emphasis on supervisory checking. 2 Issue 1 Page 54 of 127 .
5 Recommended Further Analysis It would be useful at some later date to perform an analysis of the recommendations generated by the incident reports to find out how effective they have been in reducing the occurrence of incidents in electrified areas.htm). Some form of step-change is required. 6. there were failures in the planning process that contributed in some way to the incidents. there appears to be a culture in the rail industry that encourages a focus on keeping trains running and avoiding delay. and obtain impressions of the value added by human factors analysis. 2 Issue 1 Page 55 of 127 . Rather than determine what work can be done under live conditions have a hierarchical approach that looks at the safest possible option first. There are clear barriers to be overcome – at present. and that the assessment of safety culture within the rail industry should be heartily encouraged. similar to the change that was initiated in the offshore industry following the Piper Alpha disaster. It would therefore seem that the RGSP recommendation is much needed. and try to find a safer alternative.steelci. This training would need to raise awareness of the conditions under which complacency can impair safety performance. A system that asked for all electrified area working to take place during a T3 possession would not fit within this culture. This would also provide the opportunity to perform a reality-check of the recommendations from this report with these organisations. etc. as this complacency was another of the common causes listed in the previous section. 6. and would need to be supplemented with a hazard awareness training and training effectiveness monitoring scheme. Reviewing these incidents suggests that to some extent behaviours of workers are being influenced by a ‘can-do’ culture that seems prevalent within the rail industry. having work areas and isolations with different limits.Benefits This would help to tackle the issue of poor risk awareness by helping to ensure that critical information relating to hazards and risks is effectively communicated.6. This is resulting in workers taking risks in the belief that they will gain acceptance from their colleagues and managers for getting the job done. It is recommended that a review of Standards covering this requirement is undertaken. This should involve making contact with the organisations involved in the incidents and finding out how well the recommendations were received. However. providing the wrong map of underground services.org/publications/main_publications_fs. For example. A checking (or auditing) process is required to identify these problems early when they arise.6. An obstacle in the preparation of this report has been the availability and inconsistency of information contained within Formal Inquiry Reports. and the documentation that discusses how to go about ‘changing minds’ is available from the Step Change website (http://step. ineffective briefings. The Railway Group Safety Plan (RGSP) already contains a recommendation for Railway Group members to assess safety culture. This recommendation would also help to address another common cause.4 Checking the Planning Process On a number of occasions. A parallel to the change that is required can be drawn from the implementation of the RIMINI approach for protection of lineside workers. planning work for red-zone working when there is a T3 possession the following week. it would not address the whole issue. such as ongoing maintenance activities. Report No. and whether they have been implemented. The petrochemical industry is living proof that this can be achieved.
Once this process was complete. For the chosen error type. the observable error type). a predictive error analysis was conducted using the task-based risk assessments developed by OLE and DC electrification specialists from Balfour Beatty Rail. memory.6. determine how likely it is that recovery will be successful. The technique is driven by a task analysis. are clearly more difficult to recover from because detection and recovery Report No.7 Predictive Error Analysis As part of the human factors input to this project. that was applied to the incidents described in the main body of this report. Secondly. 2 Issue 1 Page 56 of 127 . The method used to conduct this analysis was a predictive form of the technique used to examine the occurrence of error retrospectively. In order to tie the assessment results to the analysis of incidents reported earlier. which do not manifest themselves in any way (i. decision or action) that might lead to the error as described in (ii). Predict the types of error (perception. Determine the opportunities for recovery from the error described in stages (i) to (iv). based upon TRACEr Lite.e. Although this form of analysis is based upon the same model as the methodology used for retrospective analysis in the main body of the report. predictive error analysis is also concerned with the opportunities which exist to recover from the error. which could occur whilst working in AC. each task was checked against the incident data to determine whether human performance of that task had been a causal or contributory factor in any of the incidents that were analysed. Firstly. which describes what happens in terms of the human information processing system of the person making the error. and how likely successful recovery would be. Errors. they remain inside the head of the person making the error). In order to do this. Predict the observable errors that might occur (see below for detail). because it is clearly necessary to be able to detect an error in order to be able to recover from it. the results were reviewed by electrification specialists from Balfour Beatty Rail over a period of two days to check the feasibility of the errors predicted. missing a step out of a procedure). or DC electrified areas.e. determine the most likely error mode (a definition of how the error type manifested itself). Where stage (v) indicates that there are recovery opportunities. On completion of the analysis. An initial meeting was held at The Keil Centre’s Edinburgh office to thoroughly explain the rationale behind the results and ensure that the electrification specialists were comfortable with interpreting the data. references were made to the severity ratings assigned to tasks in the original risk assessment. ‘observable error type’ refers to what indication there would be to a third party that an error had been made (for example. The objective of this exercise was to predict the types of human error. which in this case was substituted for the risk assessment referred to above. This is used in addition to the ‘error type’. The process for the assessment is as follows for each task in the task analysis: (i) (ii) (iii) (iv) (v) (vi) Determine the performance shaping factors associated with that task. there are some notable differences that the reader needs to be aware of to avoid confusion. there needs to be some indication of how the error would manifest itself to a third party (i.
the results of the predictive analysis are presented in a series of tables accompanied by explanations of the data. 3. but within the context of the task in hand it is inappropriate.1 Results of Predictive Error Analysis In all. In each table the error type is listed first (e. This information should be interpreted in the following way: 1. 2. vegetation clearance. In such Report No. and those tasks that involve intrusive maintenance of electrical equipment. These are located in Appendix E. action error) followed by the error mode – how this error might occur (e. boundary maintenance). the term ‘extraneous act’ describes an action that is not required within the task sequence. Inspection and Servicing – tasks involving only visual inspection of equipment or servicing equipment. Each of these classifications will now be examined in more detail to provide: an indication of the types of errors predicted in each case an indication of the severity ratings associated with the tasks that make up each class of task whether or not any of the incidents reviewed for the main body of this report involved any of the tasks included within the classification. 3. For each observable error type predicted.g. Note that in some cases. These groups of tasks were examined to identify any common themes in order to allow them to be identified in this report. 2 Issue 1 Page 57 of 127 . there are several ways in which the observable error could come about (e.are in the hands of the person making the error. perception or action error). interfere with performance of the tasks in this group.g.g. The initial results of the analysis revealed that the tasks could be divided into three different groups based on the types of error that could occur when performing the tasks. in that an action would be seen that could be recognised as being surplus to requirements for the task. 6. conductor rail) and maintenance work in the vicinity of the track (e. Inspection and maintenance in proximity to electrical source – inspections of components of electrified systems (e. The following classification system was adopted: 1. Finally.g. selection error). Review the list of performance shaping factors for each group. 2. Maintenance – intrusive maintenance of electrical equipment or working in close proximity to energised electrical equipment. by action.e.g. but which has nevertheless occurred. those tasks that involve working in close proximity to electrical equipment that may or may not be energised.7.7. Errors that do manifest themselves such that others (or electronic systems) stand more of a chance of being recovered. An extraneous act can be observed by a bystander.2 Interpreting the Results of the Predictive Error Analysis In the pages that follow. which describes how human information processing might break down and result in the predicted observable error. This section begins by providing an indication of the types of error that might be observed (e. there is then a table. Review the list of tasks associated with each group. They comprised tasks involved in inspection of equipment and facilities (i.g. those that do not involve physical contact with energised equipment). An extraneous act is not necessarily an incorrect thing to do in itself. an extraneous act). 6. These factors could Review the details of predicted errors. 205 tasks carried out in electrified areas (both AC and DC) were analysed.
e.e.7. all feasible ways in which the error could be generated are explained in the table5. The tasks in this group received a risk rating between 10 and 20 in the risk assessment (i.4 Inspection and Maintenance in Proximity to Electrical Source List of Tasks See list at Appendix E. if so the assessed likelihood that recovery from the error would be successful.7. an extraneous act). low risk). not that all of them would occur together to produce the observable error. 2 Issue 1 Page 58 of 127 . The table then goes on to show whether or not the analysis predicts that recovery from the error would be possible. 5 This means that any of the error types could result in the observable error. 4.e. and a brief explanation of what happened in each case. and a comments field to provide additional explanation. Performance Shaping Factors The tasks covered by this classification were most likely to be affected by the following factors: Weather Noise and distraction Alertness / concentration / fatigue Lighting Familiarity with the task Details of Predicted Errors The most likely way that an observer would be able to tell that an error had occurred would be observation of an unrequired and incorrect action (i. 6.cases. or tool. The following table describes how this could occur: Extraneous Act (unintentionally taking action that is not required) Error Type Error Mode Recovery Is Recovery Success Possible? Likelihood Yes Low – may not have time to intervene Comments Action error or incorrect positioning of a hand.3 List of Tasks See list at Appendix E. including isolation Selection error Action (unintended physical action) None of these tasks was involved in the incidents that were reviewed for this project. All tasks in this group received risk rating of “5” or less in the risk assessment (i. Inspection and Servicing 6.special consideration should be given to this task. results in contact with energized equipment . Following the table there is a list of incidents reviewed for this study. they are moderate to high risk). which involved relevant tasks from the risk assessment. Report No.
2 Issue 1 Page 59 of 127 . one of the most likely ways in which errors would manifest themselves would be in extraneous acts (unrequired actions that are also incorrect). Adwick in August 2000 involved vegetation clearance but involved a violation by one of the workers rather than a human error. The following tables describe how these situations could occur: Extraneous Act (unintentionally taking action that is not required) Error Type Error Mode Is Recovery Recovery Success Possible? Likelihood Comments Action Selection error (unintended Yes physical action) Low – may not have time to intervene Action error or incorrect positioning of a hand. The Leighton Buzzard incident of June 1985 also involved vegetation clearance. including isolation Action Too Much Error Type Error Mode Is Recovery Recovery Success Possible? Likelihood Comments Perception No Perception Yes Low to Moderate – more time to intervene Going too close to the energized if a worker is seen to equipment because of failure to be getting too close to perceive proximity to it energized equipment Two of the incidents reviewed for this project were related to one of the tasks from this group – manual vegetation clearance. Report No. errors within this group of tasks are also likely to manifest themselves by operators taking more action than is required to perform the task (e. or tool.g.Performance Shaping Factors The tasks covered by this classification were most likely to be affected by the following factors: Weather Noise and distraction Alertness / concentration / fatigue Lighting Familiarity with the task Details of Predicted Errors As with the inspection and servicing tasks. getting too close to live equipment) a type of error expressed as ‘action too much’.special consideration should be given to this task. results in contact with energized equipment . but there was insufficient information in the investigation report to determine the human factors cause. In addition to this.
Handover/take-over. cleaning one of several section insulators. driving a vehicle off before all of the workers are on board. Competence testing. 2 Issue 1 Page 60 of 127 . high risk).g. Due to the range of tasks involved the factors likely to affect the performance of those carrying out the tasks is extensive. Alertness/concentration/fatigue. This includes intrusive maintenance of electrical equipment or maintenance in close proximity to energised electrical equipment. e. failing to conduct live line testing prior to commencing work. Recency of training. e. Procedure availability/access/location. Training quality.e. All tasks in this group were rated above 20 in the risk assessment (i.g. Mentoring quality. getting too close to an energised electrical source. Right Action on Wrong Object – the choice of action is correct but the selection of object is incorrect.5 Maintenance List of Tasks See list at Appendix E. Omission – an action that should have been taken is missed out.7. Complacency. Report No.g. Performance Shaping Factors This was by far the largest group of tasks identified. e. e. Extraneous Act – action that is not required and is incorrect. and therefore presented more opportunities for error. Familiarity with task. but selecting a live one by mistake. Weather. Action too Early – action that occurs at the wrong time. Lighting. unintentionally starting work before testing has been completed. as shown in the following list: Time pressure. The analysis suggested that there were a number of types of error. unintentionally touching a wrench to the energised conductor rail.g. Staff availability. e. Action in Wrong Order – an action is conducted at the wrong point in a sequence. Team maturity. The following tables describe the predicted errors in more detail. covering a range of tasks involving maintenance work on or around electrical equipment. Level of experience. Supervision.g.6. Team co-ordination quality. including the likelihood of recovery. which could lead to the occurrence of these observable errors.g. e. Temperature. Non-standard activities. The following list describes the ways in which errors could manifest themselves in this type of task: Action Too Much – doing more than is required. Details of Predicted Errors Many of the tasks in this group were more complex than in the previous two groups.
g. which is in some co-workers to detect a way lacking decision failure.special consideration should be given to this task. Accessing equipment too Low – could be difficult if early because equipment the misperceived status information has been information is credible misperceived Accessing equipment too early because the checking Low – difficult for others procedure or other to detect a memory failure information relating to equipment status is forgotten Low – difficult to recover Making a judgment about the is basis of judgment is safety of working around live credible. including isolation Action Too Early Error Type Error Mode Is Recovery Possible? Recovery Success Likelihood Comments Perception Misperception Yes Memory Forget information Yes Decision Misjudgement Yes E. 2 Issue 1 Page 61 of 127 . results in contact with energized equipment . or tool.Action Too Much Error Type Error Mode Is Recovery Possible? Recovery Success Likelihood Comments No Perception Perception Yes Low to Moderate – more time to intervene if a worker is seen to be getting too close to energized equipment Going too close to the energized equipment because of failure to perceive proximity to it Extraneous Act (unintentionally taking action that is not required) Error Type Error Mode Is Recovery Possible? Recovery Success Likelihood Comments Action Selection error (unintended physical action) Yes Low – may not have time to intervene Action error or incorrect positioning of a hand. Right Action on Wrong Object Error Type Error Mode Is Recovery Possible? Recovery Success Likelihood Comments Perception Misperception Yes Low to moderate– relies on further checks by individual or detection of mistake by co-workers Low to moderate– relies Memory Misrecall Yes Action taken on a live piece of equipment instead of the intended de-energised or nonelectrified equipment due to perceptual confusion between pieces of equipment Action taken on a live piece Report No. also difficult for equipment.
leading to work commencing with equipment energized Forget Information Misrecall Yes Yes Decision Poor decision Yes / plan As above Twelve of the incidents reviewed for this project involved tasks that fall into this group. isolation limits. 2 Issue 1 Page 62 of 127 . live line testing) or check equipment status prior Low to Moderate – reliant to commencing work. or confirm isolation caused by a poor decision or plan. Further details of these incidents are provided below: Report No. information the worker being forgotten (e. Action taken on a live piece of equipment instead of the intended de-energised or nonelectrified equipment due to action error resulting in inappropriate selection of equipment Action in Wrong Order Error Type Error Mode Is Recovery Possible? Recovery Success Likelihood Comments Memory Misrecall Yes Low Misrecall of work procedure leads to a step in a procedure being taken out of sequence Omission Error Type Error Mode Is Recovery Possible? Recovery Success Likelihood Comments Memory Late/missing Yes action Failure to confirm isolation in place (e. Of these.on further checks by individual or detection of mistake by co-workers Action Selection error Yes Low – difficult to intervene in time to prevent harm of equipment instead of the intended de-energised or nonelectrified equipment due to misrecall of the equipment reference number. seven were classified as errors and the remaining five were violations. which does not include provision for standard checks.g. etc. forgetting procedure) or misrecall of information As above As above As above As above Failure to check of equipment status.g. Could on co-worker to spot the be due to memory failure omission before harm or stemming from a late or last minute realization by missing action. location.
At Tollerton in May 2001. Investigation of the incident suggested that this was a violation rather than an error. Recommendations covered the conduct of line testing in complex areas and provision of safety communications training. workers received electric shocks during preparation for work on the OLE. their performance will naturally vary). At Marston Green in July 2003. The knowledge that was most likely missing was that he could check the contents from the label (or perhaps where the label was located). a worker died when he climbed on top of a wagon. a worker received an electric shock when redistributing the load on top of a wagon. The most effective solutions to prevent such errors of action involve removing the hazard or physically separating the worker from the hazard. a worker received an electric shock when cleaning a section insulator. two workers were injured whilst maintaining a rail flange lubricator when an uninsulated spanner contacted the energised conductor rail. a lookout was electrocuted when he joined in with the replacement of insulator pots. and the use of rail shields. Two errors were identified.e. At Hemel Hempstead in August 2001. The worker was alone at the time and so the circumstances behind the accident are unclear. At Oakley in August 2003. the same person does not always perform to the same level of precision. checking procedures and audits of COSS briefings. Report No. a worker was electrocuted whilst replacing cable tubing near the rails. a human error analysis suggested that the most likely course of events were that the worker made a poor decision regarding climbing on top of the wagon due to a lack of knowledge.At East Croydon in September 2002. This is in line with the predicted action (selection) error leading to an observed extraneous act. ensuring properly insulated tools are used. At Ranskill in October 1998. At Harlow Mill on the 5th May 2002. Recommendations covered a oneman procedure for removing earths. 2 Issue 1 Page 63 of 127 . A human error analysis was performed which suggested that this was an action error (specifically a selection error because it was a physical action) and that this was most likely due to human variability in physical performance (i. The analysis of this incident indicated that this was a violation rather than an error. However. Recommendations covered effective communication training. and there may have been a lack of knowledge regarding the dangers of overhead lines. guidance on high-risk handovers. the recommendations covered working under T3 conditions. and auditing of records of working hours. refresher training and opportunities to develop skills. the use of situational risk assessments. presumably to check its contents. In the analysis of this incident. and familiarity with goods wagon labelling. a worker was killed when he removed the earth end of a long earth before the line end. At West Croydon in October 2001. This was an error on behalf of the Engineering Supervisor. One was an action error (unclear information on location of live equipment). who had made a poor decision based on a faulty mindset. Recommendations covered the provision of training on the hazards associated with AC equipment. This was found to be a violation rather than an error. several workers received electric shocks during the unloading of track by a crane that fouled the overhead line during a renewals project. Analysis revealed that this was a perception error stemming from a misperception that a colleague had removed the line end. Analysis of the incident revealed that this involved a violation rather than an error. the other was a perception error where information was misperceived due to confusion. At Doncaster Belmont in December 2001. one on behalf of the worker and one on behalf of the person giving the briefing. effective communications training.
the analysis of the sample of electrification incidents resulted in a series of recommendations directed towards preventing or mitigating similar events in the future. Most tasks do not provide the opportunity for decision-making errors. although these should receive priority attention. 6. Recommendations covered coinciding worksite and isolation limits. It is not recommended that such error-reduction measures only be applied to the higher-risk tasks. The results of this predictive analysis can be used to generate more generic recommendations that can be applied to a greater range of tasks. associated with tasks that have been classified under the higher risk classification categories in the risk analysis (i. 2 Issue 1 Page 64 of 127 . memory. although these were also predicted.e. The incidents that were reviewed were.7 Generic Recommendations These recommendations are presented grouped by the type of error (perception. In the main body of this report. It is therefore important that means of reducing the likelihood that such errors will occur in future. Based upon the output from the predictive analysis.At Liverpool Street in November 1999. The analysis suggested that this was due to an error of perception (failure to perceive information). two workers were burned when they ruptured a buried 132Kv oil-filled HV cable. At Handsworth in March 2002. 6. The review of previous incidents reported in the main body of this document suggested that the most common form of error was the perception error. the following section documents some generic recommendations. A number of incidents have involved error types that have also been predicted for other tasks that so far. which occurred four times in those incidents reviewed. those that have a rating of 20 or 25 on a 5 x 5 scale). Other tasks should be given similar attention once the higher-risk tasks have been addressed. or if they do their impact can be lessened. action and memory errors. and regular audits by the site safety authority. They are intended to provide a starting point from which to develop a specific recommendation to fit a particular situation. Recommendations included planning documentation with enhanced detail and procedures for encounters with buried objects. and to the best of our knowledge. Report No. None of the incidents reviewed included memory errors. These recommendations are generic.7. largely. have not been involved in incidents.7. There were also two action errors and two decision-making errors. which should be considered for reducing the likelihood and impact of errors for all tasks that receive higher risk classifications in the first instance. a worker was injured when he made contact with the OLE whilst climbing some scaffolding. An incident at Dock Junction in February 2002 involved workers trying to dismantle a scaffold under OLE following a shortening of the possession which meant that there was not time to complete the job safely. decision or action) that they are designed to address. should be afforded a high level of importance. caused by their expectations regarding what was buried at the worksite. This was classified as a violation rather than an error.6 Summary The predictive analysis of human error conducted to supplement the risk assessment of tasks conducted in electrified areas suggested that the predominant types of error that would be encountered would be perception. It was felt that decision-making errors would be more likely in planning and management tasks than in manual tasks. to apply them they should be interpreted in the context of the specific task (or tasks) to which they are to be applied. Analysis suggested that this was a perception error (misperception of correct location by the contractor) caused by confusion between different locations on the station that looked similar.
Train and educate personnel to develop situational awareness skills to reduce the likelihood that they will distract others during performance of critical tasks and increase the likelihood that errors caused through distraction will be identified early. 2 Issue 1 Page 65 of 127 . 2. Provide means of clearly distinguishing de-energised equipment from energised equipment (e. 3. Raise awareness of the influence of distraction and preoccupation on error rates and encourage personnel to consider these as part of a personal risk assessment prior to conducting work. etc).g.g. 4. Personnel should feel able to raise preoccupations and distractions that they feel could affect safety through programmes such as “Time Out for Safety”. Raise awareness of conditions under which tunnel vision (focussing on one piece of information at the expense of others) can cause difficulties (e. Introduce checking procedures to be followed by people operating in the more risky conditions to trap errors prior to incidents. Report No. marker boards.Perception Error Recommendations 1. emergency conditions and other high-stress situations). 5. brightly coloured isolation permits.
considering potential side effects of actions. Review procedures regularly with members of the workforce to reduce ambiguity and complexity and ensure that they are fit for purpose. Ensure that all personnel are provided with adequate practical skills training to meet operational requirements. Ensure that all personnel receive the training required to enable them to fulfil their duties safely and reliably. Provide aides mémoire for critical tasks to reduce memory load. Introduce procedural checks by other personnel to detect errors in time to correct them. 2 Issue 1 Page 66 of 127 . Introduce a formal training evaluation procedure to identify shortcomings in existing training interventions. Provide regular emergency training to reduce the probability of memory failure. For critical actions. 3. 5. 2. use multiple personnel in the decision-making process to increase the probability that decision-making failures will be identified early. Ensure that training is in place to overcome potential confusion associated with habits from previous jobs or changes to equipment. 2. 3. Ensure that multiple team members have the information required for critical tasks to introduce redundancy. Action Error Recommendations 1. checking the validity of plans as the situation unfolds. Raise awareness of conditions under which thoughts and habits can intrude and encourage team members to be more vigilant under such conditions. 6. 3. 4. Time Out for Safety.g. 6. 4. Report No. Design the working environment to account for variation in body size and inaccuracy of positioning (e. Introduce situational awareness training to help ensure that all team members are aware of all stages of the decision-making process and are able to intervene should there be a problem. Provide training in decision making in order to increase skills in integrating several information sources. make steps wide enough to accommodate 5th percentile female shoe size up to 95th percentile male shoe size). Ensure that newly trained personnel receive mentoring or supervision for a period of time to ensure that training has been successful 5. through existing open reporting systems. Design training to include a period of practice prior to returning to the job. etc. 7.g. Decision Error Recommendations 1. 2.). 4. Raise awareness throughout the workforce of the safety impact of lack of learning and encourage the reporting of instances where they feel risks exist (e.Memory Error Recommendations 1. effective and easy to use and remember.
Telecommunications. Power Distribution and Off Track activities. 2 Issue 1 Page 67 of 127 . Numerical Value 1 2 3 4 5 Likelihood Improbable Remote Occasional Probable Frequent Definition Extremely unlikely to occur Unlikely to occur Likely to occur once Likely to occur more than once Extremely likely to occur Numerical Value 1 2 3 4 5 Severity Negligible Minor Noticeable Major Fatal Definition Little risk of injury or disease Minor injury that may result in less then one shift loss time Lost time injury of more then one shift Accident or Incident reportable under RIDDOR Loss of life Report No. B or C Competency for working on or near live electrical equipment. PTS and any specific competence requirement required for the task such as Level A. Degree of risk (rating) = likelihood x severity.1 Task Identification and Risk Analysis Methodology This element of the research has included the identification of tasks that are undertaken by maintenance and renewal teams on the electrified railway.g. RT/E/S/21070. In excess of 600 tasks performed on the operational railway were identified and risk assessed. Risk assessments were carried out in accordance with a risk rating approach using a 5 x 5 matrix. RT/E/P/24001 and RT/E/C/27018 refer. Contact Systems (both AC and DC). The scope of tasks examined included Permanent Way. The breakdown of tasks against each function is shown in the table below: Function Permanent Way Signalling Telecommunications 750 V DC Conductor Rail 25 kV AC Overhead Line Power Distribution Off Track Activities Total No.7 7. Signals. The base line controls included basic competence e. which include vegetation clearance and drain cleaning. The panel reviewed the risk associated with undertaking each task and ranked it in terms of likelihood and severity assuming that only base line controls were in place. a panel of experienced personnel from within the Balfour Beatty Rail Group of Companies was formed. of Tasks Identified Overhead Line DC Conductor Rail 62 62 88 83 43 47 N/A 36 49 N/A 23 24 51 61 316 313 Having identified the various tasks.
The degree and extent of the additional control measures should reduce the residual risk down to one that does not put employees at undue risk. 2 Issue 1 Page 68 of 127 . Monitor work to ensure no increase in risk Ensure controls are in place. Additional control measures for these activities could include additional training. The column on the extreme right of the charts highlights areas where additional control measures could be applied to bring the risk down to a tolerable level. which came out as red risks with only basic controls being applied. only two falls into the red risk category and requires additional control measures to be applied to bring the risk down to a tolerable level. Shown in the chart at 7. physical stops on the telescopic poles to restrict their height or in the extreme. Monitor work to ensure no increase in risk Ensure identified controls are in place. As can be seen for these tasks. only undertaking this activity when the overhead line has been isolated and earthed. 202 of the tasks assessed fell into the red risk category with only base line controls applied.The above values are then multiplied together to give a risk ranking as follows: Likelihood 1 2 3 4 5 1 1 2 3 4 5 2 2 4 6 8 10 Severity 3 3 6 9 12 15 4 4 8 12 16 20 5 5 10 15 20 25 Risk Rating 1 to 3 4 to 5 6 to 9 10 to 14 15 to 25 Class Negligible Low Medium High Unacceptable Control Action Ensure identified controls are in place. it was decided to concentrate on those. Monitor and review work methods to further reduce risk Action required to control risk. Monitor situation Action required to modify work methods and introduce controls to reduce risk rating Having followed the format detailed above across the range of tasks identified in both an overhead line and DC electrified railway scenario. This may mean in some instances only doing those tasks under isolated and earthed conditions.2 is an example of the process adopted for a number of tasks undertaken in the category of Permanent Way Engineering. Report No. Review work methods to reduce risk. The charts shown at Appendices F1 to F10 inclusive detail the tasks. In view of the number of tasks identified. which fell into the red risk category. using surveying equipment in OLE areas that is non-conductive.
75M RA Basic Control Measures L S Total Possible Mitigation Inspections Patrolling S&C Inspections Ultrasonic Inspection (Manual) Ultrasonic Inspection (Manual) Formation Structures Fencing Tunnels Longitudinal Timbers Clearances Surveying using levelling equipment Foot Patrol and Visual Inspection of the P Way Foot Patrol and Visual Inspection of S & C Staff undertaking NDT using hand trolley Staff undertaking NDT using hand probe Foot Patrol and Visual Inspection of the P Way Structures examination by staff from Rail Level Fencing inspection from track or cess Foot Patrol and Visual Inspection of tunnels Foot Patrol and Visual Inspection of timbers Foot Patrol and Visual Inspection of the P Way Staff undertaking optical survey of track None Identified None Identified None Identified None Identified None Identified None Identified None Identified None Identified None Identified None Identified Equipment coming into contact with live OLE 1 1 1 1 1 1 1 1 1 3 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 15 20 All staff undertaking these tasks have been trained and certificated to PTS requirements All staff undertaking these tasks have been trained and certificated to PTS requirements All staff undertaking these tasks have been trained and certificated to PTS requirements All staff undertaking these tasks have been trained and certificated to PTS requirements All staff undertaking these tasks have been trained and certificated to PTS requirements All staff undertaking these tasks have been trained and certificated to PTS requirements All staff undertaking these tasks have been trained and certificated to PTS requirements All staff undertaking these tasks have been trained and certificated to PTS requirements All staff undertaking these tasks have been trained and certificated to PTS requirements This subject to be given further consideration especially where gauges are used which could come into contact with live OLE Telescopic staffs can come into contact with OLE Rails Rail lubricator servicing Rail lubricator replacement Fishplate oiling Staff working at rail level Staff working at rail level Staff working at rail level None identified None identified None identified 1 1 1 5 5 5 5 5 5 All staff undertaking these tasks have been trained and certificated to PTS requirements All staff undertaking these tasks have been trained and certificated to PTS requirements All staff undertaking these tasks have been trained and certificated to PTS requirements Note: The possible mitigations are for consideration only. Report No.75 600mm <600mm M 2.2 Example of Task Identification and Risk Assessment Process Task List and Risk Assessment for Permanent Way Engineering in OLE Area Proximity to OLE Task Description Key Electrical Risk >2. Where tasks indicate an unacceptable risk then appropriate control measures should be developed to bring the residual risk down to a tolerable level.7. 2 Issue 1. Page 69 of 127 .
trained and where required certificated in meeting the requirements contained within. From discussions with personnel who undertake both maintenance and renewal activity it has become apparent that the requirements of RT/E/S/29987 are not as widely understood as they should be. Planning is seen as key in mitigating risk and careful consideration needs to be given when undertaking activities such as renewals involving plant and equipment. electrified lines that danger may arise are supplied with. A number of incidents Report No. 2 Issue 1. strict adherence to the requirements as detailed in RT/E/S/29987 regarding safe systems of work should be observed.75 Metre’ rule is likely to be breached in respect of identifying the need for an isolation or other safe system of work employing the use of PPE. and live pantographs and other roof mounted electrical equipment on trains.7. The document states that before any work is carried out on or about the electrified lines. It is a requirement of the document to produce a risk assessment and a written method of working. the work shall be subjected to risk assessment in relation to the danger from the live parts of the OLE. and that the availability of the document to all pertinent employees working on or near to electrified lines is often restricted. It is recommended that the application of RT/E/S/29987 is further investigated and that Network Rail undertake targeted audits to confirm that Employers are adequately discharging their responsibilities in accordance with the clause highlighted above.’ Whilst the ‘Green Book’ (RT/E/S/29987) has been the ‘bible’ of electrification staff for many years and they afforded some degree of protection and overseeing in the pre-privatised railway industry to other functional groups. Consideration needs to be given to activities where the ‘less than 2. Insulated tools etc. RT/E/S/29987 is quite specific regarding the responsibilities of Employers and states in Module 1: ‘Responsibilities of Employers Employers are responsible for ensuring that persons under their supervision who are required to work on.3 7. Dependent on the proximity to the OLE of the intended work the levels of preparation. c) understand the requirements which apply specifically to them and that they shall make themselves acquainted with. review and authorisation vary. Electrified Lines. In both cases. Full application of the ‘Green Book’ including the requirement to undertake risk assessment will mitigate the risk to personnel from contact with a live conductor. the same cannot be said in today’s disaggregated railway. b) fully understand the requirements relating to obtaining an emergency isolation. Electrification poses many hazards but the premise of ‘work within the rules and you will be safe’ rings true. Page 70 of 127 . and will be held responsible for the observance of such requirements.1 Summary Overhead Line Areas In the majority of cases the red risks can be managed down to a tolerable level by the application of the requirements of RT/E/S/29987 Module 3 which details the requirements for the management of electrical risks involved when work is to be carried out on or about 25 kV A.C. or so near to. the relevant Modules forming Network Rail Company Specification RT/E/S/29987 and that all such persons: a) fully understand the requirements relating to their personal safety.3. Special consideration should be given where the distance is likely to be less than 600mm.
3 states that ‘Certain activities. The incidents at Harlow Mill and Marston Green (See Sections 6. In the event that it is not possible to secure an isolation then the next consideration should be to adopt alternative safe systems of work. and will be held responsible for. It further states that Employers and Persons in charge are responsible for ensuring that all persons under their supervision including contractors. No activity should be performed on the electrification equipment itself without first obtaining an isolation and following the requirement for a ‘Permit to Work’ (Form C).have occurred where lifting machines located outside the area defined as being ‘on or near’ have made contact with the live overhead line. 7. It is recommended that consideration be given to undertaking further research that examines the merits of mandating a hierarchical approach to safety of persons working on or about the electrified line such that the first consideration is always the safest possible way (isolation). Changes to the planned activity should not take place unless the changes are re-planned and the risks re-assessed. the observance of all such instructions. GO/RT3091 further states that ‘Work on near the conductor rail shall be carried out under the protection of a Conductor Rail Permit except as shown in instruction 2.3.2 states ‘Where it is not reasonably practicable to isolate the conductor rail and issue a conductor rail permit certain activities may be carried out with the conductor rail live.8 and 6. (See Tollerton Incident May 2001 Section 6. are supplied with and are competent in the use of these instructions and that each person: (a) Understands which of the instructions apply to them and that they must make themselves acquainted with. Instruction 43. (b) Fully understands the instructions relating to their personal safety. 2 Issue 1. Many of the red risks can be managed down to a tolerable level if the requirements of GO/RT3091 Issue 2 are followed. As stated in the section relating to the OLE it is further recommended that Network Rail establish the application of the requirements of GO/RT3091 across the industry.3’ Instruction 2. the likelihood of contact with an energised conductor is greatly increased due to it being at ground level and adjacent to the running rail.15).1. the activity should be fully risk assessed at the planning stage and the need for a suitable ‘Safe System of Work’ identified. a safe system of work for each activity must be established.11) are typical where late notice change was effected without re-planning and re-assessing the risk. Page 71 of 127 .4.4.4. There is some merit in looking at the approach the industry has taken to the safety of people working on or near the line as defined in RT/LS/S/019. GO/RT3091 states that every person working on or near a line electrified by the DC conductor rail system must be supplied with a copy of the instructions relevant to their duties. especially vegetation clearance is another area where there have been a number of incidents (See Adwick 2nd August 2000 Section 6.2 DC Conductor Rail Areas In DC conductor rail areas. Once again. putting people’s safety at risk. Off track activities. Report No.4.1.2). In these circumstances. for example those shown in Instruction 43 can be carried out with the conductor rail live subject to the establishment of a safe system of work.
It is recommended that this work is revisited and mandates issued as to which activities are allowed to be performed with the conductor rail live and which are not. The incidents at East Croydon in September 2002 and Oakley in August 2003 involved undertaking work on the conductor rail under live conditions. which went into some depth on the requirements of safe systems of work related to the proximity of the activity to the conductor rail. Report No. Once again the planning process is key to the establishment of a safe system of work and the recommendations for a RIMINI approach to planning work in respect of danger to electrocution is re-emphasised. Much work has been undertaken in the past on enhancing GO/RT3091. Issue 3 was subsequently withdrawn due to other circumstances and the industry was slow to react to continuing with the other benefits that it contained. 2 Issue 1.The problem arises in the interpretation ‘reasonably practicable’ and who actually determines and authorises work on or near the live conductor rail. It is known that some work was undertaken by maintenance contractors working in the Wessex. Page 72 of 127 . Kent and Sussex areas on the identification of tasks that were performed on or near to the electrified DC line and the establishment of safe systems of work. The question of whether it was not reasonably practicable to take an isolation has to be answered. which culminated in the production and issue of ‘Issue 3’.
75m from 25kV equipment.1 Introduction This section of the report looks at some of the developments that are either available. Whenever a new device is considered the risks it may import must be considered as well as the benefits it brings (table below). The particular device reviewed in this report is the CoTEC Technology ‘Cricket’. Any device that warns of the presence of live OLE has to strike a balance between warning early enough and becoming a nuisance. It is recognised that devices of this nature could lead to improved safety and it recommended that a full review with HAZOP and field trials be undertaken in Phase 2 of the project.8 Developments 8.1 Specific Developments Personal Live-Line Indicators (LLI) These devices are intended to warn individuals of the proximity of 25kV live equipment. This clear discrimination ability is essential and commends this device for further operational trials. that the introduction of such devices has to be undertaken in a controlled and rigorous manner that looks at all facets of safety. It is a small battery powered device. It could be argued that had such a device been available and in use at the time of the Marston Green incident in July 2003 the staff who were preparing to work on the OLE would have received a warning and stopped work. If the right balance could not be found for this application. Phase 2 of this project is seen as an ideal vehicle to progress worthy items in a logical and controlled way such that their introduction and availability is improved. Product acceptance must be considered as the warning given could clearly be considered as safety critical but may be tempered by the fact that it is an additional control measure. Although there has been much work done already in the development of safety enhancing devices the industry has been slow to respond in their introduction and as a result use has been extremely limited. Report No. Where overhead line personnel are working adjacent to live OLE concern remains that any LLI would alarm too frequently. not intended to be the first line of defence or to supplant any of the existing control measures applied in the Isolation process. Page 73 of 127 . 8. It should be attached to hard hats or only offered towards the OLE on an as required basis. It will start to alarm (beep) from approximately 2. Early trials by Balfour Beatty Rail Projects (mid 2005) shows that the device performs as described. Further operating details are available from the manufacturer.75m increasing the rate of beeps as that dimension decreases.2 8. the size of a normal key fob. This is not an inherent fault of the device but shows the nature of working adjacent to live equipment. They do not replace Live-Line testers as part of the isolation process. It is recognised however. consideration could be given to fitting to baskets or platforms on OLE rail mounted maintenance machines.2. in particular NOT giving spurious results beyond 2. 2 Issue 1. in the process of being developed or where benefit is seen from undertaking development to enhance safety or improve efficiencies without compromise to safety.
CE compliant Consider wearing two Report No. there is no physical last line of defence. Number of Permits to be issued MUST be identified at planning stage. As above plus challenge the planning of the isolation Provide clip that is specifically designed to fit a hard hat Keep in pocket and only use on specific occasions Not first line of protection Battery test facility. work content or personnel. LLI gives warning before individual touches live equipment 4) Personnel will ignore Nominated Persons briefing and rely on LLI Wearing of LLI must not affect or detract from NP reaching clear understanding with COSS. exacerbated by late changes to plan. (This should occur whether LLI’s are in use or not). and decision made regarding alternative method of issuing Permit to ensure timely effective briefing of safe working limits to all COSSs. Site audit of all Permit holders to test understanding of safe working limits. 2 Issue 1. All of the above in this column are trying to prevent this situation occurring but ultimately. LLI does not remove or change the responsibility of the NP to reach clear understanding with the COSS regarding safe working limits 3) Group or individual fail to follow briefing and stray beyond safe working limits All of the above in this column can be factors in this most critical residual risk. 2) COSS does not understand briefing COSS does not brief his own workgroup COSS does not brief relieving COSS Knowledge of COSS regarding OLE and Permits Content and efficacy of COSS training Time identified for briefing Poor practices may have become the norm. Alternative method of issuing Permit not considered COSS training will be enhanced by Network Rail to include extra content and emphasis on the receipt and briefing of OHL Permits. LLI will warn individuals or RMMM that they are approaching live 25kV equipment. Consider numbering individual LLIs and issuing to named staff. LLI gives warning before individual touches live equipment Wear personal Live-Line Indicator 5) LLI not worn correctly and fails to warn at safe distance 6) LLI alarms frequently and is considered a nuisance 7) LLI fails completely Familiarity with new piece of kit LLIs being passed to individuals who have not received training in its use As cell above plus has the work been planned to reduce or eliminate residual 25kV hazards? Identified personnel must be trained and records kept. Page 74 of 127 . RT/E/S/29987 (Feb 05) has new section enabling alternative methods of issuing OHL Permits to be considered and implemented. Briefing covers safe working limits and residual 25kV hazards. Consequence: Death or serious injury Mitigation Mitigation failure mode: Factors: Control measure LLI control measure Competence and Person 1) Nominated Person does not give effective briefing Nominated Person briefing and issuing of Overhead Line Permit to each COSS whose work activity requires isolation. professionalism of Nominated Too many Permits to be issued within a given time to deliver effective individual briefings Nominated Person competence training and assessment regime has been thoroughly overhauled by Network Rail into national package.Hazard: Contact with OLE energised at 25kV.
the tester should be immediately quarantined so that the logs can be retrieved and. Compliance with testing on every occasion is impossible to check at present. The latest C31 tester can store hundreds of tests. it will encourage personnel to follow the procedures and thereby improve safety. Depending upon memory available. and if managed properly would discourage future non-compliance. ranging from testers that were developed and manufactured by Regional Electrification Depots. The author has discussed this with Co-TEC: Existing C31 testers can be modified to carry out data logging.2. It is doubtful whether they would meet the requirements to gain appropriate certification today. It will not be able to log a de-energised check only.3 Data Logging in Live-Line testers Live-Line testers are used to check that overhead line equipment has been removed from all sources of electrical supply. It relies on the competence and discipline of the Nominated or Authorised person to carry it out correctly. 2 Issue 1.2. and also when it was removed from the line (or the line de-energised). Although introduction of this facility will not in itself prevent an incident occurring. The tester will write over the oldest test in the log when the memory is full and a new test is carried out. The older BR devices were designed and manufactured prior to the introduction of the Machinery’s Directive and do not carry CE marking. but once it is full. Page 75 of 127 . A further complication is the ongoing maintenance and repair. above 11kV or below 10. Newly introduced testers have not been without their problems and there have been instances of failure. 8. the tester will write over the oldest data first just as before. Discussions with one leading manufacturer of testers for the Electrical Supply Industry has indicated a reluctance on their part to enter into development because of the relatively small numbers involved and the uncertainty of product acceptance.8. In the event of an incident. if necessary. the tester would be able to store the last 10 to 20 tests. The innovation of data logging in the live-line tester can improve that. which could have resulted in injury. The microcontroller on these testers can tell whether the line voltage is high or low (i. sustained by a safe professional culture in their workplace. CoTEC can supply a communication device that plugs into the existing socket at the back of the tester so that owners can interrogate their C31 testers as desired. It can log the precise measured voltage. the date and time the tester was applied to the energised line and the time it was removed (or the line de-energised). The memory will take much longer to fill compared to the modified testers.9kV).2 Live Line Testers There are many variants of live-line testers in use on the rail network. It may be used to record a de-energised check so long as there is at least some residual voltage left in the line to measure (because it can measure actual voltage rather than just high or low). Existing C31 testers may have the complete control boards replaced to give full functionality but that will be more costly. It is recommended that the specification and development of live line testers be pursued in Phase 2 of this project. switches or isolators. through to testers that have been adapted from those used in other industries. In both cases. Report No. as per their training. The consequences of not testing have previously been described. The benefits will be to spot check the activities of Overhead Line staff with regard to correct isolation procedure.e. That can happen because testing is not interlocked with circuit breakers. returned to CoTEC for independent verification. The tester will log the date and time the tester was applied to an overhead line carrying high voltage. nevertheless it is an option.
fixed isolation facilities in certain specific locations would bring tangible benefits: Nominated Person competence tailored to that installation (simpler. and at certain locations on the network. In order to tighten the earth clamp the tommy bar and spindle from the live-end must be offered up to the earth clamp. This statement as an absolute requirement should be checked before developing the equipment or business case for a section of Overhead Line having fixed remotely controlled earths for the issue of issue of Overhead Line Permits. The principle is that the earth end clamp does not have a tommy bar. Fewer personnel required (no portable earths to erect or manual switching to carry out) Personnel removed from the hazard of erecting portable earths or manual switching Less time taken to issue an Overhead Line Permit Report No. Micro-switches on actuator (Morris Line Equipment) RF injection & detection (AEA technology & Network Rail) At present. The process can be speeded up if all switching required is carried out remotely but the extent of the planned isolation and nature of the fixed infrastructure often means that manual switching is required on-site. In addition to this overarching reason. engaging with the spindle of the earth clamp and enabling it to be tightened. there are 20 different live-end and earth-end combinations that must match to successfully engage. there is long-standing concern of how to prove in absolute terms that a remotely controlled device has moved into the earth position.2. The current accepted practice is to use circuit breakers as their integrity is considered high enough to guarantee that a circuit has been connected to earth (for the application stated above). the process of switching off. The earth that it provides has never been included on a Form B in connection with the issue of an Overhead Line Permit. They provide a positive deterrent to applying the earth end last. testing and earthing electrification equipment relies on verbal and written communications.4 Interlocked long earths P&B Weir has introduced interlocked long earths. The interlocked long earth is a similar price to the standard long earth dependant on quantity. Notwithstanding the issues described above. This is because the current UK edict is that an Overhead Line Permit can only be issued after a Form B has been completed with portable earths applied. Information exchanged is recorded on paper forms and telephone conversations with the Electrical Control Room (ECR) are recorded to tape or digitally. both face-to-face and by telephone. Use of interlocked long earths would contribute to avoiding incidents such as Ranskill in October 1998 where a fatality occurred when the earth end of a long earth was removed first. only a collar that will spin without turning the spindle/clamp. some work has already taken place on a solution. In this latter case. Page 76 of 127 . Modern switchgear includes the option of earthing the OLE that it is connected to. If extra assurance were required for Form B earths then an engineering solution would be required. specific earthing circuit breakers are provided to perform this function. 8. That habit-forming need is a powerful addition in ensuring the earth is applied in the correct order. 8. less broad range of knowledge required).2. 2 Issue 1.5 Earthing devices This report has considered pole applied portable earths. it does introduce a real need for the authorised person to apply the earth end first. they are used to reduce the area affected by an emergency isolation by enabling adjacent OLE sections to be energised. isolating. To prevent the enterprising Lineman cutting off the Live-end tommy bar for permanent ready use.It is recognised that devices of this nature could lead to improved safety and it recommended that a full review with HAZOP and field trials be undertaken in Phase 2 of the project. Whilst this system is not an absolute barrier to applying the live-end first.
6 DC Isolation and Earthing There has been much concern regarding the ergonomics of transporting and applying short circuiting straps and other equipment on the DC railway when effecting an isolation. We recommend that further work be undertaken in Phase 2 of the project to develop a tester that is both useable and reliable. which is looking specifically at the design of short circuiting straps in respect of transportation. 8. 8. as the availability and likelihood of securing an isolation within daylight hours was remote the task of both spatial and profile gauging of the conductor rail could not be done effectively. are currently undergoing a trial on the network. application and security of electrical connection.8 Conductor Rail Gauging Following the incident at Oakley in 2003. the required safety case. There have been numerous failures which could have resulted in direct injury or providing a wrong indication of status. 2 Issue 1. It is recommended that the task of gauging of the conductor rail is looked at in Phase 2 of this project with the objective of defining a suitable design of gauge (non contact) that enable effective gauging to be undertaken without putting the operative at undue risk. panel indications for energized and earthed status of the OLE or indications communicated digitally to hand-held devices. Balfour Beatty Rail Maintenance took a decision to ban live working on DC conductor rail equipment.Possible to have discrete areas where all residual 25kV hazards are eliminated Isolations do not have to be bought in. of course. the change of culture and. it was felt that work on the conductor rail equipment could be planned within a full possession and isolation. The requirement for new fixed infrastructure. New devices. Page 77 of 127 . This project both recognises and supports that work. developed by London Underground. compliance with legislation makes this area of work particularly onerous. Initial feedback indicates that these new devices are also unwieldy and that the indicator lights are not as visible as they should be in daylight.2. RSSB have awarded a separate research project. whether that is interlocking in SCADA preventing out-out-sequence operations.2. The present design of gauges requires the operative to be within 300mm of the live conductor rail thereby placing him in a position of danger. This project supports the need for a better test instrument that affords operatives with a useable and reliable piece of equipment.2. At that time. For a fixed installation where the output and risks are clearly defined there is further opportunity for communication to be replaced or reinforced with digital outputs. However.7 DC Test Equipment The equipment traditionally used to test the status of the DC conductor rail (box of eggs) is both primitive and cumbersome. 8. Report No.
The review has identified the problem of over issue of overhead line permits on some major work sites due to bad practice and misinterpretation of the rules.16 The over issue of permits to COSSs and Machine Controllers whose work activity does not require an isolation is another area of concern and needs to be addressed in both training and cascade briefing. It has looked at how isolation and earthing practices have evolved since the introduction of rail electrification. Knowing and understanding where DEPs are not available will allow action plans to be formulated to mitigate this risk in the future. The project recognises the good work already undertaken on the changes to Standards and Processes for Nominated and Authorized Persons. The continuation of this Group is seen as key in striving towards continuous improvement in the promotion of safe working practices in electrified areas. 2 Issue 1. under the guidance of the 29987 User Group. refresher training and recertification training. It has raised the profile of the Isolation activity and the overall quality of training and assessment. The review has identified the hazards that exist from 25kV OLE. recognized that this non-compliance is being addressed by the 29987 User Group. The publication could be used in NP/AP training and to raise awareness and understanding of these hazards to COSSs and PTS holders through their training and briefing. We therefore recommend that Phase 2 of this project reviews both PTS and COSS course content and with the collaboration of Network Rail and Sentinel produces new slides. it is however. All candidates are subject to ongoing assessment. in the main. This is a positive practical step to improving and maintaining the competence of nominated and authorised persons. training plans and assessment tools. Report No. The level and content of electrification training on both PTS and COSS courses is a cause for concern and we recommend that a review is undertaken and improvements identified. It is recommended that enhanced communication of rulebook requirements in this area is undertaken. We would recommend that a national database of DEPs be progressed in Phase 2 of this project. During late 2005 into 2006 the competences of isolating DC 3rd Rail. and isolating/accessing railway distribution equipment have been added to the national Sentinel scheme. The review has highlighted non-compliance issues with Module 6 of RT/E/S/29987 in regard to isolation planning. The continued use of long earths in the absence of DEPs is a cause for concern especially when considering the Ranskill incident in October 1998 when a worker died whilst removing a long earth. Throughout the review. Although several organisations have produced their own internal briefing material it is felt that the national training material should be enhanced. Page 78 of 127 . This development continues. it has become evident that the isolation process is based on sound principles developed from the first electrification schemes. The importance of identifying all recipients of Overhead Line Permits is covered in clause 4. This project would like to commend the Group for the good work that they have done and continue to do. It is felt that benefit could be gained from producing a publication highlighting these hazards.9 Conclusions This project has reviewed working practices in electrified areas to identify where enhancements to working practices can be made in terms of safety and efficiency. The review has concluded that the isolation process presented in RT/E/S/29987 is a well proven methodical way to achieve safe working on or adjacent to 25kV OLE.
It is disappointing that the development of GO/RT3091 has now been going on for an inordinate amount of time and many of the benefits identified at Issue 3 have not been realised to the benefit of enhanced safety in third rail areas. RSSB and the HSE. These results can be used to inform the analysis of previously reported incidents. Page 79 of 127 . Prior to gaining access to incident reports. It is recognised that Network Rail are aware of these differences and are addressing the issue. it was anticipated that some time would be available to interview witnesses and persons involved in the incidents to gain a deeper understanding of the behaviours involved. As part of the human factors input to this project.18 and concludes that this distance should be treat as a formulaic distance that is judged to be a safe working distance from the OLE rather than an electrical clearance. Review a sample of railway incidents involving electrified equipment to determine why the people involved behaved the way that they did. i. The review recognised that GO/RT3091 remains in a state of flux whilst discussions on the most appropriate way forward are agreed between Network Rail. Report No. This guidance can be used to identify ways of reducing the likelihood of teamwork failures in future. There is also best practice guidance available on teamwork within the rail industry. due to the volume of information in the reports received and the consequent analysis time required.e. However. Predict the types of human error that could feasibly occur considering the tasks that personnel are required to perform in and around electrified areas. a predictive error analysis was conducted using the task-based risk assessments developed by OLE and DC electrification specialists from Balfour Beatty Rail. this was not achieved. the use of distance markers should be considered. Previous research has provided a great deal of practical information on why people behave (intentionally or unintentionally) in a way that goes against safety procedures. It is recommended that a detailed review of electrical clearances in these documents takes place with the various stakeholders and a uniform approach agreed. 2 Issue 1.The origin of the nine-foot rule is discussed in clause 4. The Human Factors element of the study set out to achieve the following objectives: Review existing literature to identify any previous work on electrified areas to avoid duplication of effort. intentionally. Research into distance judgement suggests that even experienced crane operators find it very difficult to judge clearance from overhead lines accurately. Research into communications errors during railway maintenance suggests that the primary cause of such errors is the design and usability of communications procedures. Review of electrical clearances to earth has identified differences in the various publications covering this issue and in particular in the Railway Safety Principles and Guidance Part 2 Section C. which is written in such a way as to make translation into recommendations relatively simple. unintentionally or because of the influence of company safety culture. In cases where raising part of a vehicle could expose the occupants to the risk of electrocution. The review has concluded that there are minor differences to the forms and procedures used in the isolation process driven by Electrical Control Room and Route. including recommendations for the reduction of such behaviours in the future.
Report No. A number of innovations that have recently been developed. The predictive analysis of human error conducted to supplement the risk assessment of tasks conducted in electrified areas suggested that the predominant types of error that would be encountered would be perception. The fatality at Oakley in August 2003 gave this new impetus but progress has been slow. Some 600 tasks performed across all disciplines were risk assessed as part of this review. Of these. It is recognised that the identification of risks in third rail areas was initiated following the introduction of Issue three of GO/RT3091 but this work stalled upon its withdrawal. which could occur whilst working in AC. based upon TRACEr Lite. which will offer improvement. that was applied to the incidents described in the main body of this report. which in this case was substituted for the risk assessment referred to above.The objective of this exercise was to predict the types of human error. some 200 fell into the high-risk category requiring additional control measures to be applied to bring the residual risk down to a tolerable level. are in the process of being developed or where a development would enhance safety or efficiency without detriment to safety are presented at Section 8. It was felt that decision-making errors would be more likely in planning and management tasks than in manual tasks. Page 80 of 127 . The method used to conduct this analysis was a predictive form of the technique used to examine the occurrence of error retrospectively. or DC electrified areas. It is recommended that further work be undertaken In Phase 2 of this project to introduce developments. The technique is driven by a task analysis. In the majority of cases. 2 Issue 1. An area of concern in the introduction of innovation or development is the apparent lack of change management culture within the industry. Most tasks do not provide the opportunity for decision-making errors. although these were also predicted. action and memory errors. It is recommended that this work is re-initiated and tasks that cannot be performed under live conditions identified and people made aware. which delays introduction of good ideas and does not make them visible. applying the rules laid down in either RT/E/S/29987 or GO/RT3091 will result in specific risk assessment of the task and a safe system of work to be developed thereby lowering the risk to a tolerable level.
what the consequences could have been (what’s the worst that could happen) and get them to come up with the suggestions for how to do the same job more safely the next time. it is felt that the national standard should be enhanced. When an undesired behaviour is observed.7 Recommendation 6 .6 Recommendation 5 – Electrical Clearances to Earth A review of electrical clearances to earth has identified differences in the various publications covering this issue and in particular in the Railway Safety Principles and Guidance Part 2 Section C.5 Recommendation 4 – PTS and COSS Training It is recommended that a review of the level and content of electrification training on both COSS and PTS courses is undertaken and any enhancements identified. 10.3 Recommendation 2 – Vertical Slice Audits It is recommended that vertical slice audits of the isolation process be undertaken to determine the effectiveness of the Standard and the process. They revolve around management or employee observations of work areas to identify both safe and unsafe behaviours taking place. 10.e. 10. training plans and assessment tools. 10. It is known that some Regional information already exists and it would be beneficial to gather this information and using best practice turn it into a national database for distribution to maintenance. why they did it. rather than punishing the individual. Safety observation schemes are designed to aid behavioural change by using the principles of providing feedback to reinforce the required behaviours. cascade briefing to industry through Safety Net or other suitable media. The concept then is to provide positive reinforcement for the desired (i. safe) behaviour whenever it is observed. The idea is that workers get to know that behaving safely brings recognition and will therefore tend to join in.2 Recommendation 1 – Communications It is recommended that when changes to the rules occur. 10. renewal and project based organisations.1 Introduction Recommendations identified whilst undertaking this review are detailed within the main body of the report. Report No. It is recommended that a detailed review of electrical clearances in these documents takes place with the various stakeholders and a uniform approach agreed.4 Recommendation 3 – National Database of DEP Locations It is recommended that a national database of DEP locations be progressed. poster campaign. It should also determine compliance with GE/RT 8024 and include the requirements of RT/E/S/29987.Safety Observation Schemes It is recommended that the concept of Safety Observation Schemes be further researched under Phase 2 of this Project. Page 81 of 127 . Each audit should start with the isolation request through planning to the issue and understanding of the Overhead Line Permit(s) on site.10 Recommendations 10. This section provides a brief summary of those recommendations. Although several organisations have produced their own internal briefing material. which it is felt appropriate to progress in Phase 2 of this project. This could take the form of industry wide alerts to re-iterate the requirement of the rulebook. 10. it will require the collaboration of Network Rail and Sentinel to produce new slides. enhanced communication to publicise the changes be effected. For this recommendation to be successful. 2 Issue 1. the concept is to: (a) (b) (c) (d) sit down with the individual and get them to explain what they did. The aim should be to get the individual committed to doing the job more safely next time.
and obtain impressions of the value added by human factors analysis. It is recommended that a review of Standards covering this requirement is undertaken. This should involve making contact with the organisations involved in the incidents and finding out how well the recommendations were received. 10.Greater Emphasis on Supervisory Checks Related to the previous recommendation. 10.12 Recommendation 11 .13 Recommendation 12 – RIMINI Approach It is recommended that consideration be given to undertaking further research that examines the merits of mandating a hierarchical approach to safety of persons working on or about the electrified line such that the first consideration is always the safest possible way (isolation). Page 82 of 127 .9 Recommendation 8 .Introduce Safety Communications Training A number of incidents seemed to involve incomplete or ambiguous information passed between team members. providing the wrong map of underground services. 10.11 Recommendation 10 .Checking the Planning Process On a number of occasions. and that when they did occur they were not very thorough.Further Analysis It is recommended that further analysis on the implementation of recommendations emanating from inquiry reports be undertaken to find out how effective they have been in reducing the occurrence of incidents in electrified areas. There are clear barriers to be overcome – at present. planning work for red-zone working when there is a T3 possession the following week.10. A checking (or auditing) process is required to identify these problems early when they arise. Organisations should be required to place a greater emphasis on supervisory checking. Kent and Sussex areas on the identification of tasks that were performed on or near to the electrified DC line and the establishment of safe systems of work.Incident Reporting An obstacle in the preparation of this report has been the availability and inconsistency of information contained within Formal Inquiry Reports. similar to the change that was initiated in the offshore industry following the Piper Alpha disaster. then the next consideration should be to adopt alternative safe systems of work. but also helps to raise the level of visibility of the supervisors. It is recommended that this Report No.8 Recommendation 7 . This would also provide the opportunity to perform a reality-check of the recommendations from this report with these organisations. there appears to be a culture in the rail industry. and whether they have been implemented. Some form of step-change is required.14 Recommendation 13 – Tasks on the DC Third Rail It is known that some work was undertaken by maintenance contractors working in the Wessex. 10. 2 Issue 1. 10.10 Recommendation 9 . For example. A great deal of work has been conducted in the recent past to develop guidelines for workers on how best to communicate safety information to make sure that the relevant information is correctly understood. having work areas and isolations with different limits. there were failures in the planning process that contributed in some way to the incidents. A system. the evidence emanating from a number of the formal investigation reports seemed to suggest that the frequency of supervisory checks of worksites tended to be very low. etc. In the event that it is not possible to secure an isolation. which should be used to check that work is being done according to plan and the prescribed procedures. 10. and try to find a safer alternative. which encourages a focus on keeping trains running and avoiding delay. which asked for all electrified area working to take place during a T3 possession. would not fit within this culture.
10. Page 83 of 127 . 2 Issue 1.Live Line Testers It is recommended that the specification and development of live line testers be pursued in Phase 2 of this project.Conductor Rail Gauging It is recommended that the task of gauging of the conductor rail is looked at in Phase 2 of this project with the objective of defining a suitable design of gauge (non contact) that enable effective gauging to be undertaken without putting the operative at undue risk.16 Recommendation 15 – Development .17 Recommendation 16 – Development . Report No. 10. 10.work is revisited and mandates issued as to which activities are allowed to be performed with the conductor rail live and which are not. 10.Live Line Indicators It is recognised that devices of this nature could lead to improved safety and it recommended that a full review with HAZOP and field trials be undertaken in Phase 2 of the project. 10.15 Recommendation 14 – Development . No working with exposed torso or legs (wearing of shorts) should be permitted.19 Recommendation 18 – Mandated use of PPE in DC Conductor Rail Areas To minimise the risk of electrocution it is recommended that Network Rail mandate the use of appropriate PPE for all staff who work on or about a DC conductor rail area. Appropriate in this context means full covering of the torso.18 Recommendation 17 – Development .Live Line Data Loggers It is recognised that devices of this nature could lead to improved safety and it recommended that a full review with HAZOP and field trials be undertaken in Phase 2 of the project. arms and legs. The Human Factors element of this review has also made individual recommendations against each incident and these are presented against each incident in the main body of the report.
2003 Team-working in the Rail Industry Milestone 2 Report on Lessons Learned from Other Industries. 2003 Team-working in the Rail Industry Pilot Study Methodology. RSSB 2004 Team-working in the Rail Industry Milestone 1 Report on Rail Industry Team-working Study. Version 1. A. 2004 Safety Critical Rule Compliance – Toolkit Evaluation and Final Report RSSB. RSSB. 3 CIRAS Analysis Bulletin covering period June 2000 to February 2002 Team-working in the Rail Industry – The Journey Guide. Young. How to Apply the Astonishing Power of Positive Reinforcement.. RSSB. W. and Lowe. RSSB.. C. RSSB. RSSB 2003 Team-working in the Rail Industry Milestone 3 Report on Metrics for Measurement of Team Performance. 2003 Team-working in the Rail Industry Milestone 6 Report on Pilot Trial Setup. 2 Issue 1. D. RSSB. R. Bergeron. (1999) Bringing out the Best in People. H. Megaw. E. D. M. J-J. International Journal of Occupational Safety and Ergonomics. 2003 Safety Critical Rule Compliance – The Solutions Toolkit – Part 3 Simplified Compliance Toolkit.Guidance on Electric Traction Systems BS EN 50122-1 1998 Railway Applications – Fixed Installations. 2 No. RSSB. Page 84 of 127 . 2003 Team-working in the Rail Industry Milestone 7 Report on Results of Pilot Trial. RSSB. 2003 Team-working in the Rail Industry Milestone 5 Report on the Study to Date. Comparison of Two Methods for Judging Distances Near Overhead Power Lines. McGraw-Hill GL/RT1252 Production & Management of Electrification Isolation Documents Railway Safety Principles and Guidance Part 2 Section C . 2004 Safety Critical Rule Compliance – The Solutions Toolkit – Part 4 Examples. Vol. S. Part 1 – Protective Provisions Relating to Electrical Safety and Earthing Report No. The Analysis of Communications Errors During Track Maintenance (undated copy via personal communication) Imbeau.. and Bourbonnierre. Paques. RSSB. 2003 Team-working in the Rail Industry Milestone 4 Report on Definition of Preliminary Best Practice Guidelines. (1996). RSSB. 2004 Daniels.. S.11 References NIOSH Alert May 1995 – Preventing Electrocutions of Crane Operators and Crew Members Working Near Overhead Power Lines Gibson. E.
sanctions to test and circuit state certificates RT/E/S/21070 Competence of persons working on or having access to Electrical Power supply equipment RT/E/S/21085 Design of earthing and bonding systems for 25kV AC electrified lines RT/E/S/29987 Working on or about 25kV AC Electrified Lines Report No.Network Rail Safety Information Bulletin No IMM/GE/001. August 2004 Traction Return Circuit Continuity Bonds BR 12034/16 Railway Electrification 25kV a.R. GL/RT1254 Electrified Lines Traction Bonding GE/RT8024 Persons Working on or near to AC Electrified Lines GE/RT8025 Electrical Protective Provisions for Electrified Lines GO/RT3091 DC Electrified Lines Instructions RT/E/P/27154 Procedure for the use and care of BR Type Testers RT/E/S/27203 Specification for the provision of isolation. earthing and indication facilities where local isolations are permitted on AC Electrified Lines RT/E/C/27017 Competence Management Systems for work on Electrification and plant Systems RT/E/C/27018 Training of persons working on or having access to electrical power supply equipment RT/E/P/24009 Competence requirements for Electrical Control Room Operators RT/E/S/21067 Instruction for making out. 2 Issue 1.c. Design on B. issuing and cancelling HV Permits to work. Page 85 of 127 .
2 Issue 1. Page 86 of 127 . Report No.Appendix A Possession Pack WON 38 Names omitted to ensure compliance with data protection act and security purposes.
Report No. 2 Issue 1. Page 87 of 127 .
A N Other@nowhere. Please ensure all staff park with consideration to local residents. A N Other@nowhere. Possession Pack prepared by : A N Other Date: 08th February 2005 Signature : Worksite Limits: Report No. A N Other@nowhere. keeping noise to a minimum and remove all litter. A N Other@nowhere. A N Other@nowhere. Page 88 of 127 . Failure to do so will result in staff being barred from site. A N Other@nowhere. A N Other@nowhere. A N Other@nowhere. A N Other@nowhere. A N Other@nowhere.05 (Saturday-Monday) Held at: Romford Date: 08th February 2005 Note: The personnel listed below were present during the Co-ordination meeting and / or briefed and agree with the co-ordination of this possession. 2 Issue 1. Name A N Other A N Other A N Other A N Other A N Other A N Other A N Other A N Other A N Other A N Other A N Other A N Other Representing NWR Planning NWR NWR OHLTES NWR OHL NWR Track Services NWR S&T Liverpool St NWR NWR Rail Scape NWR S&T NWR NWR Contact Number 00000 000000 00000 000000 00000 000000 00000 000000 00000 000000 00000 000000 00000 000000 00000 000000 00000 000000 00000 000000 00000 000000 00000 000000 Email Address / Fax Number / Hand A N Other@nowhere.Appendix B Possession Pack WON 47 POSSESSION PACK Possession Managed by Network Rail Liverpool Street To Bethnal Green / Bow / Cambridge Heath WON 47 Item No. A N Other@nowhere.
00 Mon Name A N Other A N Other A N Other Telephone 00000 000000 00000 000000 00000 000000 Place of Issue Recipient Contact no Issued By Work Content Principal Contractor Work Content Isolation Req’d COSS(s) COSS(s) Access point Plant Site Manager Additional Info Principal Contractor Work Content Isolation Req’d COSS(s) COSS(s) COSS(s) Access point Network Rail Defect Rail N/A A N Other A N Other Norton Folgate Hand Tools 00000 000000 00000 000000 PPS Ref W2004/631597 Site Times Actual Mileage 01.00 Sun to 04.50 Sun 01.00 Egress point Norton Folgate Report No.00 Sun to 17.00 Sun 18.00 Mon 00m00ch – 02m40ch 00000 000000 00000 000000 00000 000000 01.00 20.00 Mon 04.00 – 08.00 Mon 04.40 Sun 01.00 to 18. Page 89 of 127 .00 Sun 17.10 Sun 15.00 Norton Folgate Egress point Network Rail S&T Maintenance N/A A N Other A N Other A N Other Norton Folgate PPS Ref W2004/864860 Site Times Actual Mileage 01.00 Sun to 08.00 – 04.40 Mon 01.00 to 08.00 Mon Isolation / Permit Issuing Part 2: Contractor NWR Engineering Supervisor: Times 01.10 Sun 15.00 08.00 Sun 04.Work Site / Limits 00m00ch to 00m60ch 00m00ch to 01m00ch 00m00ch to 00m60ch 00m00ch to 02m40ch 00m00ch to 02m40ch 00m00ch to 01m60ch Lines Affected Up & Dn Subs Up & Dn Subs Up & Dn Subs Up & Dn Mains/Electrics Up & Dn mains/Electrics Up & Dn Fasts Start Time 01.40 Mon Finish Time 08.00 – 20.00 Sun Finish Time 04.00 Sun 08.00 Sun 08.00 Mon Isolation / Permit Issuing Part 1: Contractor NWR Lines Affected UP & Dn Mains/Electric/Fasts/Subs Limits of Isolation 305-306-303-304-311-312Start Time 01.20 Sun 04.50 Sun 04. 2 Issue 1.00 Sun 00m00ch 01m00ch – 01.00 08.
the human information processing system is divided into four key elements: perception. the outcome of the activity is stored in memory and can be recalled in terms of experience the next time they perform a similar task. in turn. memory. For each of these there is a defined set of human error modes. In order to allow human factors analysis to be conducted as part of the investigation process itself. they perceive information from the world around them using their senses and compare the information they receive through this process to information held in memory. to help them to understand what this means. recent events. when a person is completing a particular task. etc Make decision based on perceptions and information from memory Take action based on decision Figure C1: Human Information Processing System Report No.Appendix C Human Factors Analysis Techniques Human Error Analysis The human error analysis technique is based upon a methodology called TRACEr (Technique for Retrospective Analysis of Cognitive Error) developed for use in Air Traffic Control to determine what the underlying causes of errors that contributed to incidents were. and then performs some action in accordance with the decision (this might be a physical action such as opening or closing a switch. decision and memory as shown in Figure C1. the methodology was developed to be more usable by the nonspecialist and more practically focussed. and has been used as the basis for the tool that is used in this study. The resulting methodology is known as TRACEr Lite. For example. the procedure used first identifies all human errors that played a part in an incident. The technique is focussed on determining why errors are made and what the organisation can do to defend against similar occurrences in the future. Perceive information from outside world Memory of training. if a person testing an overhead line with an analogue line tester sees the needle swing to 7kV. action. experience. Error modes. and which indicate in what way the perception. and then determines from the evidence available which part of the human information processing system malfunctioned resulting in the error. procedures. Briefly. expectation bias where someone expects to see or hear something and therefore assumes that they have done so when in fact they have not). which are a more detailed description of the error. or following. Typically. TRACEr was initially developed for use by human factors specialists to analyse incidents in parallel to. are also associated with a set of error mechanisms. the formal incident investigation. Once the action has been completed. etc. or a verbal action such as giving an instruction to someone else in the work party).g. Page 90 of 127 . Error mechanisms are descriptions of the ways in which the human mind works which can lead people to commit errors (e. The person uses this information to make a decision on what to do next. decision or action process broke down. by either removing opportunities for error or reducing the impact of the error should it recur. they recall information from their training. For the purposes of investigation. 2 Issue 1.
Signal Strength Failing to perceive something that is vague or of short duration. or a failure to calculate or understand information Considering Side-Effects Not foreseeing side effects or long-term effects of a decision Mind Set Sticking to a faulty plan. there are only a certain number of error mechanisms that apply. belief or interpretation. 2 Issue 1. Tunnel Vision Fixating on one piece of information to the exclusion of other relevant information Overload A large amount of incoming information or too much information to retain in memory Distraction / Preoccupation Distraction by a momentary event or a longer term preoccupation Insufficient Learning A problem due to lack of experience or application of training Mental Block Inability to recall the required information Failure to integrate Failure to integrate several pieces of information. Page 91 of 127 . position or function or confusing information in memory that is similar. Some mechanisms are relevant to more than one type of error. fluency or intonation Perception Error Memory Error Decision Error Action Error Report No. if the analyst decides that an error is a form of perception error. Therefore.The error modes associated with each of the four error types are shown in the following table: Error Type Perception Misperception No perception Memory Late/missing action Forget information Misrecall information Decision Misjudgement Poor decision/plan Late decision/plan No decision/plan Action Selection error Unclear information Incorrect information Error Modes Certain error mechanisms relate to certain error types. even despite evidence to the contrary Knowledge Problem Lacks required knowledge due to training Decision Freeze Decision 'freeze' due to complexity or emotion Human Variability Lack of manual precision. The relationships between error types and error modes are detailed in the following table – the ticks indicate which error mechanism is appropriate to which error type(s): Error Mechanisms Expectation Expect something to take place so strongly that you believe that it has occurred even if there is evidence to suggest otherwise Confusion Confusing information or objects of similar appearance.
The first step of the analysis is to identify the antecedents that were either present. a memory error). Environment . a perception error). despite the handle at ground level being in the open position (i. etc. why the error has occurred. All of the above deal with analysing the error in terms of a failure of information processing.Number.Language. etc.Workload. personal to the individual who made the error. quality. Report No. The overriding benefit of using such a technique is that it allows the investigator to be very specific about the actions recommended to prevent recurrence in the future. habits or task interference effects cause a person to do or say something unintended Other Slip Other slip of the tongue. etc An investigator’s worksheet has been developed to ensure that we conduct a systematic analysis of human error covering all of the above aspects of human error. etc. Alternatively. i. Procedures & documentation . etc. and conventional incident investigation techniques would not provide sufficient detail of the human errors involved to allow the investigator to define clearly the most appropriate course of action. The action you would take would clearly be very different in each case. and so an assessment of the conditions that were likely to have affected performance (known as performance-shaping factors) is built into the analysis.e.Noise. clarity.Social & team . may occur because the individual did not see that the blade of the switch had remained in the jaws. action etc. time pressure.e.Error Mechanisms Intrusive Thoughts / Habits Thoughts. an error. An analysis tool has been developed to guide an investigator through the process of identifying what triggered a behaviour and what the consequences of the behaviour were to the individual involved. both internal and external to the individual who made the error. the individual may have forgotten that the switch had been closed for a specific reason and needs be opened again at the end of the job (i. the necessary trigger for the behaviour was missing. which results in a switch that is usually open being left closed. accuracy. 2 Issue 1. Perception Error Memory Error Decision Error Action Error The process of breaking an error down in this way allows the investigator to identify the root cause of the error in psychological terms. so in the example.Recency of training. Training & experience . This is an internal phenomenon. Page 92 of 127 . ABC analysis forms the basis of many behavioural safety programmes used across industry sectors. temperature. which describes the Antecedents (or triggers) to a Behaviour and the Consequences of that behaviour from the point of view of the person behaving. is strong influenced by the conditions under which we work. etc. the intention would be to trigger the behaviour of driving within the speed limit.Personal . pen. etc. Human-machine interaction .Handover. etc. ABC Analysis ABC analysis is a well-known form of behavioural analysis. These cover the following topics: The task . absent or inadequate and therefore triggered the behaviour.Domestic issues.e. Communications . Human performance. For example. If the sign had been present. however. driving over the speed limit may have occurred because there was no sign to indicate the speed limit.Trust. This is not included in the report because the analysis techniques themselves were not agreed as a deliverable on this project. supervision. For example.
there were more good reasons to violate the procedure than there were to obey it. immediate and certain consequences. and the consequences that would provide reinforcement for it – positive ones to encourage uptake of the desired behaviour and negative ones to discourage the undesired behaviour. if a worker knows they will be punished for not wearing full PPE. It is therefore providing effective reinforcement against the behaviour of not wearing PPE. then the investigator has evidence to suggest that the consequences of the behaviour for the individual were to save time. the supervisor. To explain briefly the use of these terms in this context. the consequences for the violation were both positive. Daniels. but not when the supervisor is absent. For example. Therefore. If speed cameras provided positive. this consequence would be considered positive.g. and the ever-present potential consequence of causing harm to themselves or others. In the example above. Having determined the triggers and consequences for the undesired behaviour. Where appropriate. but this is not continued once the trigger for the behaviour. reductions in road tax. immediate or future. immediate and certain consequence) they will tend to comply with the rule when a supervisor is present. Most people would also consider the subjective likelihood to be uncertain. get approval from the person holding the meeting.The next step of the analysis is to determine what the consequences of the behaviour were from the perspective of the person involved. and so from the point of view of the person behaving. Certain or uncertain refers to the subjective assessment of the person behaving of the likelihood of the consequence in question. the first consequence – saving time – is likely to have been positive from their point of view. negative. A related stage in the analysis is to determine. and certain or uncertain. Page 93 of 127 . 2 Issue 1. However. 1999) tells us that people find positive. Speed cameras are another example. Except in this case they are looking to identify the triggers that would help to encourage the behaviour in the first place. is removed. So in our example of the person exceeding the speed limit. taking the example of exceeding the speed limit. for example. The second consequence – getting approval from the person holding the meeting – would be assessed in a similar way. If this information were provided at interview. This consequence would therefore be assessed as negative. whether the consequences identified were likely to be positive or negative. the individual may have stated to their passenger that they were late for a meeting and needed to speed up. Behavioural research (e. immediate and certain consequences of driving within the speed limit for your entire journey by calculating your average speed (e. vouchers for money off fuel) then this would reinforce the desired behaviour of driving within the speed limit more effectively than providing negative consequences. immediate and certain consequences much more powerful reinforcers of behaviour than other classes of consequences. the analyst is then guided through the same process for the desired behaviour. from the point of view of the person behaving. (a negative. The third consequence – causing harm to themselves or others – would be assessed as negative. so it would be immediate. Immediate or future refers to whether the consequence occurs immediately after the behaviour or at some point in the future. future and uncertain. positive and negative are self-explanatory. immediate and certain. they expect that it will not happen this time or that this is not something that will happen to them. the consequences that would discourage this violation were negative. It would also have been seen to be a consequence that would be received at the time or shortly after the behaviour. most people who speed do not expect this consequence to occur at the time or shortly after the behaviour. A subjective assessment of certainty at the time would probably suggest that the consequence of saving time by speeding up would be almost certain to occur. therefore this would be a future consequence. They tend to have a longer-lasting effect on behaviour than. For example. Report No. firstly.g.
it is a tool to indicate whether such an assessment should be conducted. Safety Culture Analysis Based upon research conducted in the offshore oil and gas industry. Note that this is not a tool for assessing safety culture.g. and these have been mapped on the matrix. Page 94 of 127 . a model of safety culture was developed which has since been refined and used in many diverse industries. skill level.the ABC analysis tool was used to conduct an analysis of the intentional procedural violations involved in the incidents under review. following procedures. training) against the 10 elements of safety culture that form the basis of the model. which lists a number of different types of causal factors (e. Experience in applying the model in industry suggests that certain causal factors can indicate that there is a weakness in one or more of the elements of safety culture. The elements of safety culture in the model are as follows: Visible Management Commitment Safety Communications Productivity versus Safety Learning Organisation Health and Safety Resources Participation in Safety Risk Taking Behaviour Trust Between Management and Front Line Staff Industrial Relations and Job Satisfaction Competency The causal factors that they are mapped against are: Following procedures Use of tools or equipment Use of protective equipment Lack of awareness Work exposures Physical condition Behaviour Skill level Training etc Management etc Contractor etc Work planning Purchasing etc Work rules etc Communication Report No. 2 Issue 1. This model has been developed into a simple matrix. The matrix is used to identify whether or not a recommendation from the analysis should be to assess one or more elements of safety culture in the organisation concerned.
(H) Explanation of the reasons for the procedure.3. In some cases. (O) Consequences of behaviour: The potential consequence of causing injury to self or others. Page 95 of 127 . (O) Briefings and/or training on the possible consequences of not using the correct procedure. resulting in arcing and a blown earth. (H) The NP had all required knowledge. findings stem partly from the original analysis and partly from the application of human factors. future and uncertain. Required Triggers: Reminders (e. (H) Desired behaviour: All personnel are to apply the L-D-L procedure when testing overhead line equipment to ensure that the line is safe to work on. it was necessary for the human factors analyst to make assumptions based upon the facts in the incident report. briefings.Appendix D Transcripts of Human Factors Analyses of Historic Incidents This appendix contains details of the analyses referred to under Section 6. In some cases. There were no signs to act as a reminder for the correct procedure. Acton East 21st January 2000 ABC Analysis Behaviour: The NP.1 of the main body of this report. we indicate whether findings quoted are based upon the original analysis or on this human factors analysis. posters) to ensure that all line testing equipment is serviceable before leaving the depot. Triggers: The tools and equipment at the time of the accident were present but inadequate for the task. signs. (H) A reminder in the form of a label or sign on the line-tester of the correct procedure. A finding from the original analysis is indicated by a (O) after the finding. it is not clear whether the NP was aware of the additional risks associated with not conducting L-D-L testing. (H) Lack of training for on-the job trainers (the NP in this case was instructing a trainee at the time but had no formal training qualifications). this has also been highlighted in the results of the analysis. failed to follow the Live-Dead-Live procedure designed to test functioning of the line tester.g. whilst preparing to apply earths to overhead line equipment. where this was the case. Again. 2 Issue 1.g. and a finding from the human factors analysis is indicated by a (H) after the finding. this is clearly indicated. (H) NPs to set good example for following procedures. In each case. skills and competence to do this task. (H) Although it is clear that there must have been some perceived consequence of not following the prescribed procedure regarding testing of the line (e. or other type of loss or damage would have been assessed as negative. there is insufficient information in the report to determine what this was. (H) Required Consequences: Report No. to save time). (H) In terms of the NP’s awareness of hazards and risks. this is clearly indicated in the reporting of results. Where the human factors analysis has been based upon speculation or assumption on the part of the original investigators.
therefore assumed to be so in this case. and these have a stronger influence on behaviour than other types of consequences. (H) Error Mechanism: Mind Set (i. (O & H) In addition. The live line test confirmed the earlier assumption. (H) Adwick. to the individual the proposed behaviour should be more attractive than the unsafe behaviour. immediate and certain. immediate and certain from the point of view of the person. leading to a willingness to believe the information in light of the expectation that the line was dead. Error Type: Decision error – Assumption: the NP appears to have judged that it was not necessary to use the full live-line testing procedure. immediate and certain. could have influenced his performance and made the error more likely: The accuracy of information provided by the line tester was certainly a factor in this incident. (H) Penalties if workers found not to be following correct procedure would be assessed as negative. 2nd August 2000 ABC Analysis Behaviour: The OHLE worker. hence. immediate and certain. even despite evidence to the contrary). If the tester had not been faulty. then the likelihood of this incident would have been reduced. Report No.Avoid injury to self or others. (H) Error Mode: Poor decision or plan – The decision to apply the earths was inadequate and did not consider the possibilities of defective testing equipment or switching errors. lifted a branch above his head.e. and if the tester had been subjected to pre-use test before leaving the depot the defective equipment would not have been used. and hence should be adopted in favour of the unsafe behaviour. 2 Issue 1. whilst preparing to apply earths to overhead line equipment. The switch in question was normally open. failed to follow the Live-Dead-Live procedure designed to test functioning of the line tester. The needle had stuck at 7kV and the dials were known to be prone to failure. (H) If the worker were to believe that following procedure takes longer. (H) Praise for safe acts would be assessed as positive. this would be assessed as negative. the format of the information provided via the line tester (analogue information) may have meant that determining the status of line was more prone to error. whilst cutting back a bush near OHLE equipment. (H) Human Error Analysis Behaviour: The NP. sticking to a faulty plan. (H) Performance-Shaping Factors: These conditions. resulting in arcing and a blown earth. (H) The fact that the NP was instructing a trainee at the time may have influenced performance. (H) Two of the proposed consequences are positive. immediate and certain. under which the NP was operating. belief or interpretation. (O & H) There appeared to be a high level of trust in the information provided by the line tester. causing contact with live OHLE and mild electric shock. or other type of loss or damage would be assessed as positive. immediate and certain consequences. Page 96 of 127 . The consequences of the unsafe behaviour did not include any positive.
The briefing did not cover electrical hazards (O). lacking the required knowledge due to training). and assessed as positive. Error Mode: Poor decision or plan – the decision to throw the branch did not take into account the proximity of the OLE. and would be evaluated by the individual as positive. and therefore would be more likely to encourage this behaviour to be adopted. etc (H). (O) Include information requirements for briefings in procedures. lifted a branch above his head. Page 97 of 127 . whilst cutting back a bush near OHLE equipment. etc. Desired behaviour: All workers to refrain from lifting any object above head height when working underneath live OHLE. immediate and certain consequence. (H) Assumption: It is possible that the worker felt that throwing the branch would save time over the alternative solution of carrying the branch into the undergrowth. (O) Check that sufficient awareness of hazards has been developed. or other type of loss or damage would be associated with the desired behaviour. causing contact with live OLE and mild electric shock. minimum clearances. (H) These consequences would provide more positive reinforcement for the desired behaviour than negative. This would have been viewed as a positive. (H) Providing feedback through mentoring on positive safety performance would act as positive reinforcement.Triggers: The victim did not appear to have had a full appreciation of the hazard (H). which would have been a positive. Report No. Error Type: Decision error – Assumption: it is conceivable that the victim decided it was safe to throw the branch. Human Error Analysis Behaviour: The OLE worker.e. but not anticipated to be a direct result of the behaviour and not considered certain. (H) Evaluate training to check effectiveness and modify if required. immediate and certain consequence. Procedure for the coverage of all hazards during COSS briefing does not seem to be adhered to (H). (H) Assumption: The worker may also have been seeking approval from his supervisor for getting the job done quickly. 2 Issue 1. (H) Any mentoring system or audit system could result in workers feeling they are being checked up on. and getting the branches well clear of the cess. Training does not seem to have been effective in relation to hazards and minimum clearances. which would be a negative. (O& H) Include electrical hazards in COSS briefing. Consequences of behaviour: The potential consequence of causing injury to himself or others. immediate and certain consequence. (H) Required Consequences: The consequence of avoiding injury to self or others. Error Mechanism: Knowledge problem (i. immediate and certain. or other type of loss or damage was perceived as negative. immediate and certain. Required Triggers: Better training or mentoring for all staff working in OHLE areas on the hazards.
Hither Green. future (i.report states that workers took the dangers of working around live OLE for granted. (H) Desired behaviour: All workers to wear full PPE at all times when they are exposed to hazards and potential risks to avoid injury to themselves. (H) Positive feedback for wearing correct PPE would be seen as positive.Assumption: the incident report states that the worker had not been with the company long. (H) Required Consequences: Avoiding injury to self or others. and the undesired behaviour carries more Report No. future and certain consequence. sunny. or other type of loss or damage would be considered a positive. (H) Workforce to intervene when colleagues fail to wear required PPE. (H) By introducing these consequences for the desired and undesired behaviour. or other type of loss or damage was most likely assessed by the victim as negative. clear weather on the day of the accident may have led to inadequate use of PPE (O) Consequences of behaviour: The potential consequence of causing injury to himself or others. immediate and certain consequence of this behaviour. Required Triggers: Identify whether there is more comfortable PPE available that would encourage use in all working conditions whilst still providing the same level of protection. future and uncertain. 25th July 1995 ABC Analysis Behaviour: A worker fell onto conductor rail without any PPE above the waist resulting in a fatal electric shock. (H) Negative feedback for not wearing PPE would be assessed as negative. immediate and certain. immediate and certain. set an example (H) Managers need to be seen to intervene to stop unsafe acts.e. (O) Familiarity with task – Assumption: the victim may have been unfamiliar with the task. and that the COSS had assumed that all members of the team were familiar with the hazards associated with OLE. and would help to discourage the unsafe behaviour. (H) Avoiding discomfort (due to hot weather) associated with wearing PPE on the top half of the body could have been a positive. Page 98 of 127 . it will not occur at the time of intervention) and certain consequence. (H) Negative feedback for failing to intervene would be seen as a negative. 2 Issue 1. access or location – report states that COSS had never seen a method statement for vegetation clearance in OHLE areas. Performance-Shaping Factors: Complacency . immediate and certain consequence of this behaviour. Procedure availability. the desired behaviour carries more possibilities for positive reinforcement. It is therefore probable that the assessment of risks associated with not wearing PPE was not sufficiently realistic to overcome the temptation of removing PPE to be more comfortable. There was no indication from report of what he was doing at the time. (H) Positive feedback for intervening would be seen by workers as positive reinforcement and hence a positive. Triggers: Incorrect PPE – the hot.
the COSS would have expected to get approval from his manager. (H) The possibility of having a wasted night due to not being able to commence or complete work could be seen as a negative. (H) Assumption: It is possible that by getting the job done on time. 2 Issue 1. (H) Positive feedback when work has been planned for T3 possession would be seen as a positive. immediate and certain consequence. Dock Junction. This will have the effect of encouraging workers to behave as desired over time. felt that this was still required even though the time available was one hour less than the time quoted for safe completion of the job. (H) One consequence of changing the method statement was to save time in getting the job done. future and certain consequence. future and certain consequence. something that would be seen as a positive. (H) Negative feedback when work is planned without T3 possession would be seen as a negative. Page 99 of 127 . resulting in increased risk to personnel. immediate and certain consequence. immediate and certain consequences for behaving unsafely than there were negative consequences to discourage such behaviour. as they were not advised of the status of the adjacent OHLE. there were more positive. (O & H) The expectations of others . (O) Consequences of behaviour: The potential consequence of causing injury to self or others. (O) There was not sufficient time to perform the required job safely. Provide the strong message that no job is important enough to put workers at risk. something that would have been seen as a positive. When questioned. and signed to indicate their acceptance of the revised statement of work. introducing time pressure. Required Triggers: Management are to express their expectation that all work will be completed under T3 possession/isolation or postponed. one member of the team stated that they were not aware of the electrical hazard. (H) Required Consequences: Avoiding injury to self or others. (H) Report No. (H) In this case. Desired behaviour: All work of this or similar nature to be conducted under T3 possession/isolation conditions. and when the isolation time was reduced. although whether all workers were aware of the risks they were under seems unlikely. 10th February 2002 ABC Analysis Behaviour: The COSS intentionally violated procedures regarding working without an isolation. (H) Receiving positive feedback for doing a safe job would be seen as a positive. but future and uncertain. future and certain consequence. immediate and certain consequence. This will have reinforced the unsafe behaviour. Triggers: It is known that the COSS was aware of the risks involved in changing the method statement. immediate and certain consequence of the desired behaviour.possibilities for negative reinforcement.COSS knew the scaffolding was to be removed on the date of the incident. or other type of loss or damage was likely to have been assessed as negative. or other type of loss or damage associated with the desired behaviour would be seen as a positive.
etc. access or location – The victim did not have access to documentation such as Section Z of the rulebook. more importantly. Note – the presence of a conductor rail shield would also act as a barrier to contact with the live rail. it was also not considered particularly likely. future and uncertain consequence of events at the time of the accident. but one was collected from the depot after the accident. Error Mechanism: Knowledge problem (i. lacking the required knowledge due to training). intended to promote the use of a safe means of achieving the job. (O) Consequences: The consequence of causing harm to themselves or others seems likely to have been considered a negative. 2 Issue 1. (H) Assumption: Perhaps there was an expectation that not using the rail shield would have saved time. therefore whilst injury would certainly be recognised as a negative outcome.These consequences introduce more positive reinforcement for the desired behaviour than negative. that a conductor rail shield had not been taken on the job. and did not appreciate the dangers of overhead lines. and. Performance Shaping Factors: Communication quality (from the personnel at the two depots regarding the dangers of OHLE. From the perspective of a worker on site. Error Type: Decision error – Assumption: it is conceivable that the victim decided to check the contents of the tank manually. their company having designed the process. this would then have been a positive. Doncaster Belmont. (O) The method statement. Assumption: Conceivable that the victim did not know that he could have deduced the contents of the tank wagon from the label. was not present at the time of the accident. immediate and certain consequence of the way work was undertaken. with the purpose of triggering safe behaviour by not working with the risk of exposure to energised equipment. (H) Report No.e. 2nd December 2001 Human Error Analysis Behaviour: A worker climbed on top of a tank wagon to check the contents resulting in fatal electric shock from overhead line. Page 100 of 127 . The gang were highly experienced in this task. the desired behaviour holds consequences that are more positive and is more likely to be adopted. and introduce negative reinforcement to discourage the undesired behaviour.) Procedure availability. Error Mode: Poor decision or plan – to climb on top of a tank wagon positioned underneath live OLE. East Croydon 8 September 2002 ABC Analysis Behaviour: No specific behaviour for the COSS was identified. was unavailable because one had never been written. (O) Familiarity with task – Assumption: the victim may have been unfamiliar with the task of determining the contents of a tank wagon. it was not expected to happen because of the way the job was undertaken. Triggers: A conductor rail shield. where to check the contents of the tank. There were indications that a method statement had not been developed.
Error Type: Perception error – the two men failed to identify the 132kV cable hazard. managed and minimised. leading to rupture. (O & H) Complacency – given the information these men were provided with. (O & H) Performance-Shaping Factors: Communication quality – Communications on the hazards present was not sufficiently effective. (O) Error Mode: No perception – Failure to perceive the hazard due to partially correct information presented from the planning process. It has the benefit of involving teams in working out the solution to a problem. (H) Penalties if incomplete or improper equipment used – gangs will come to expect a negative. (H) Handsworth. or other type of loss or damage needs to be promoted and accepted as a positive. immediate and certain consequence of the desired way of conducting work. providing the workers with inaccurate information and no contact through whom to obtain a quick response on actions required. expect something to take place so strongly that you believe that it has occurred even if there is evidence to suggest otherwise). (H) Positive feedback for teams that perform consistently safely and publicise their success to other teams. (H) Safety observation scheme to praise safe acts and remedy the situation – provide positive feedback for positive safety behaviour and ask those who behave unsafely to explain what the consequences of their actions could have been and how they would do the job more safely next time. Required Triggers: Produce method statements for all tasks that bear the risk of electrocution due to working in proximity to the conductor rail or OHLE (O) Required Consequences: Avoiding injury to self or others. so the gang expected the area to be free from electrical hazards. (O & H) Report No. When the CAT scan detected something. This is a positive. (O & H) Information accuracy / correctness – the provision of incorrect plans certainly appears to have had a strong bearing on the occurrence of this error.Desired Behaviour: All risks associated with working around energised equipment to be identified. (H & O) Error Mechanism: Expectation (i. they were led to believe that there was no hazard associated with their actions. The gang had already experienced striking reinforced concrete slabs in the area on a number of occasions. 2 Issue 1. This provides positive. this confirmed expectations that the buried object was another piece of reinforced concrete. Page 101 of 127 . future and certain consequence of adopting the desired behaviour. Work planning and mapping had not identified the presence of buried services at the work site. which was then tackled using heavy tools.e. immediate and certain consequences in the event of compliance with the desired behaviour. immediate and certain consequence of not using the correct set of tools and equipment. 5th March 2002 Human Error Analysis Behaviour: Workers ruptured a 132kv cable buried under ballast whilst conducting fencing renewal work. which injured two men. This led to a hydrocarbon fire.
Assumed the ES would look at the Form C before briefing the COSS’s. sticking to a faulty plan. failed to advise the ES that he had received the Form ‘C’. (O & H) Team co-ordination quality – the co-ordination of information and effort within the team lacked effectiveness. (O & H) Report No.Based upon previous experience. Error Type: Decision error . there did not appear to be any consideration of the risks involved or highlighting them. sticking to a faulty plan. belief or interpretation. Handover when work is ongoing is particularly risky. (O & H) Error Mechanism: Mind-set (i. based upon previous experience. it is therefore inconceivable that he did not know the potential consequences of not providing information on the isolation limits. decided to pin the Form ‘C’ to the wall in the SAM’s cabin. believed that the isolation limits had not changed. This was a poor decision because there were additional sources of information that could have indicated that the isolation limits were not the same.Based upon previous experience.the circumstances surrounding the job had recently changed. even despite evidence to the contrary). on receiving and signing the Form ‘C’. (O & H) Time on the job – the ES had not been with the company for long (although he was very experienced). even despite evidence to the contrary).e. Page 102 of 127 .The foreman’s plan was based on assumption. (H) Human Error Analysis 2 Behaviour: The foreman. (O & H) Error Mode: Poor decision / plan .The nightshift ES was an experienced worker. (O & H) Team communication quality – Assumption: communication within the team appeared to have broken down. resulting in relevant information on isolation limits not being briefed to other COSS’s Error Type: Decision error . 2 Issue 1. (H) Handover / takeover – the handover between engineering supervisors did not appear to be systematic or structured.Harlow Mill. belief or interpretation. (O & H) Performance-Shaping Factors: Non-standard activities. The nightshift ES. (O & H) Error Mechanism: Mind-set (i.e. although there were other sources of information that could have been consulted that would have resulted in the correct decision. (O & H) Error Mode: Poor decision / plan . decided to pin the Form ‘C’ to the wall in the SAM’s cabin. 5th May 2002 Human Error Analysis 1 Behaviour: The nightshift ES failed to provide details to COSS’s on the isolation limits resulting in workers being exposed to live overhead line equipment. even though there was evidence to the contrary available to him.
touched a live section insulator resulting in electrocution. (H) Error Mode: Unclear information . diagrams or the OHLE itself). Performance-Shaping Factors: Communication quality –Assumption: manner in which information was relayed could have adversely affected performance. Information was passed verbally with no reference to supporting material (e. position or function or confusing information in memory that is similar) – Assumption: Lack of evidence to support this. (O & H) Team co-ordination quality – the co-ordination of information and effort within the team lacked effectiveness. (O & H) Hemel Hempstead. (H) Familiarity with task – Assumption: level of familiarity with the task could have introduced complacency. Error Type: Action Error – Assumption: ED may have communicated information on the location of live equipment in an ambiguous fashion. (H) Error Mechanism: Insufficient data to make a diagnosis.g. assumption made based upon knowledge of overhead line operations – could have been confused by proximity and similarity of appearance of live sections of OLE Report No. 8th August 2001 Human Error Analysis 1 Behaviour: PS. 2 Issue 1. Page 103 of 127 . (O & H) Team communication quality – communication within the team appeared to have broken down.e. confusing information or objects of similar appearance.e. whilst conducting overhead line maintenance duties. but it would appear possible that PS misheard an instruction indicating with section insulator required cleaning (this point is disputed in the report – i. whilst conducting overhead line maintenance duties.Ambiguity of communication regarding live equipment and / or the need to clean a section insulator. ED states that he did not request any SI to be cleaned) or the location of the live equipment.Performance-Shaping Factors: Time on the job – the ES had not been with the company for long (although he was very experienced). Error Mode: Misperception – Assumption: Possible mishearing of instructions regarding areas of live equipment and / or which SI to clean (some dispute over the last issue) Error Mechanism: Confusion (i. (H) Human Error Analysis 2 Behaviour: PS. Error Type: Perception Error – Assumption: Difficult to say from the evidence. (H) Team communication quality – manner of communicating between team members was open to error. touched a live section insulator resulting in electrocution.
One worker got into basket for fear of being left behind. (H) Awareness of hazards and risks – Given the experience of the workers involved there had to be an appreciation of the hazard of working in the area. position or function or confusing information in memory that is similar). or contributed to overall confusion. resulting in electrocution. Liverpool Street. Also. resulting in a member of the contractor’s staff sustaining an electric shock. insufficient control of situation by COSS.e. There appears to have been confusion between different locations on the station that looked similar. Familiarity with task – level of familiarity with the task could have introduced complacency Team communication quality – manner of communicating between team members was open to error. 1st July 2003 ABC Analysis Behaviour: Workmen boarded and raised the basket underneath live 25kV OHLE. (O) Complacency – high degree of familiarity with the project may have led to complacency. confusing information or objects of similar appearance.Performance – Shaping Factors: Communication quality – manner in which information was relayed could have adversely affected performance. Error Type: Perception error – Assumption: It appears that information regarding the correct positioning of the scaffold was misunderstood by contract personnel. message relating to lack of Form C not strong enough. (H) Other people’s expectations . (O & H) Report No. the isolation and worksite limits did not match. which may have caused confusion in itself. Page 104 of 127 . 7th November 1999 Human Error Analysis Behaviour: Scaffolding was erected underneath live OLE by contractor. safety information and complacency in the briefing process.Workers felt authorised to begin ground level work. (O & H) Information – Assumption: Information regarding issue of the Form C potentially unclear did not explicitly state that Form C had not been issued at re-brief. (O & H) Error Mechanism: Confusion (i. but this was not enough to prevent them from putting themselves in danger. (O & H) Error Mode: Misperception – The correct location for the scaffold was not correctly perceived by the contract personnel. (O & H) Marston Green. Performance-Shaping Factors: Communication quality – in the communication of isolation limits. (H) Other people’s example . (O & H) Accountability . Triggers: Tools and equipment – It was possible for the workers to operate the interlock that allowed the vehicle to be operated from the basket under live OHLE. (O) Team communication quality – Assumption: communications within the team did not appear to be adequate as the isolation manager and the project manager were both unaware that work was to take place in the location in which it did. which further resulted in a fall from height. 2 Issue 1.COSS allowed men to enter the basket under live OHLE. (O) Familiarity with the task – Staff had worked on the project for a number of months.
immediate and certain consequence for the individual concerned.Procedure for handover of information designed for clarity. Required Triggers: Tools and equipment –Key switch interlock operation prevented on vehicles with overhead platforms and platform steering until Form C issued (H) Awareness of risks and hazards . displays . (H) The consequences of this behaviour were predominantly positive. (H) Management observation scheme – depending on how this is managed.Notice next to interlock switch in RRV to discourage operation from the basket beneath OLE. (O & H) Required Consequences: Avoid injury to self or others. or other type of loss or damage – a positive. (H) Save time in starting work – this would have been seen as a positive. (H) Other people’s expectations .Number of procedures are in place. (H) Procedures . immediate and certain consequence to the men involved. or positively reinforce desired behaviour. (H) Avoid getting home late – a further positive. the consequences are immediate and certain to the person behaving.Rules – Assumption: Rules regarding whether or not the workgroups should have been (a) on the track and (b) beginning ground level work seem to have been missing. (O & H) Consequences: Causing injury to self or others. (H) Report No. immediate and certain consequence that workers should already comprehend. (H) Procedures . and hence weak reinforcement for avoiding this behaviour. immediate and certain consequence of non-compliance. References to outdated procedures exist. but verification and compliance checking does not seem to be in place (Assumption). (H) Policies . (H) Non-compliance results in a disciplinary action (a “three strikes and your out” policy) – Introduction of a negative. immediate and certain. can be used to punish inappropriate behaviour. Page 105 of 127 . future and uncertain consequence. immediate and certain consequence for the men. or other type of loss or damage – this would have been seen as a negative. Desired behaviour: No personnel to ride in baskets or other exterior structures whilst under OLE power lines. In both cases.Policy in place to prevent use of vehicles underneath OLE. who had been informed of a delay to the isolation.Managers and supervisors to make clear safety expectations regarding OLE work. 2 Issue 1. thus would have strongly reinforced the behaviour. immediate and certain consequences for the individual for engaging in the desired behaviour. (H) Praise correct individual behaviour – this provides positive. (H) Avoid ridicule by co-workers for not getting into basket – this would have been seen as a positive.Clarify that raising basket even slightly underneath OLE increases the risk of flashover (H) Signs.
immediate and certain consequence. (O & H) Other people’s example . all personnel to refrain from engaging in work tasks. something that would have been seen as positive. was providing some of the training himself. 7th August 2003 ABC Analysis Behaviour: The lookout knelt down to engage in physical work.Oakley.The risk assessment only considered the high-level risk of the conductor rail – there was no specific assessment of the risks associated with this particular job. but the rules on this are not made explicit. This required COSS to provide on-the-job training. (O & H) Knowledge. Note – this may involve a change in safety culture. the planning process for the possession looked only at the week ahead. (H) Get approval from trackman for helping with his training – Assumption: it is possible that the lookout felt that the trackman’s thanks for helping him would be a positive. (H) Desired Behaviour: 1. It is therefore inferred that this is not officially condoned. (H) Save time – Assumption: it is possible that the lookout tried to join in work to save time. as there were other slots further ahead that would have allowed the work to be carried out under T3 conditions. and reflects on the commitment to safety of management as perceived by the workforce (link to safety culture) (H) Consequences: Causing injury to self or others. Triggers: Awareness of hazards and risks . Note . immediate and certain. but there are a number of factors that contributed to this. This could also have been an effect of time-pressure to complete the work. (H) Get approval from COSS for dealing with on-the-job training – something that would have been seen as positive. This could suggest to workers that management do not discourage such activity. or other type of loss or damage – this would have been seen as negative. The safe worksite handbook does not include any activity covering this work with the conductor rail energised. These are recorded in this analysis. rather than identifying hazards in the work area. as an experienced worker. Page 106 of 127 . immediate and certain. When on lookout duty. future and uncertain. Required Triggers: Risk assessments to include risks specific to the job in hand. both at the time of the incident and during the planning process. 2. skills.this would not have resulted in an accident if the conductor rail had been de-energised. (O & H) Other people’s expectations – Assumption: Mention made of the fact that the work had become urgent due to hot weather – was the implication that the workers felt under time pressure? In addition. 2 Issue 1.One of the trackmen was inexperienced and there was no formal training for the work. All work involving changing pots and fixings to be planned for T3 possession. Note – there is insufficient evidence to determine why the lookout disengaged from lookout duty to join in the work. (H) Report No. competence . which led to his electrocution when he made contact with the conductor rail. (H) Training only to be provided by COSS when required on-the-job.It had become custom and practice (routine violation) for this work to be conducted with the conductor rail energised. but it appears in this case that the lookout.
A number of the factors involved in this accident suggest possible weaknesses in the visibility of management’s commitment to safety and the level of risk-taking behaviour by employees. (H) Positive feedback when work has been planned for T3 possession – positive. (H) Error Mechanism: Difficult to say from the evidence which one of signal strength (Failing to perceive something that is vague or of short duration. (O) Report No. Error Type: Perception error – Assumption: It appears that the men were working as a team to disconnect the earths and that the victim believed that the live end of the blue earth had been removed through observing his co-worker. (O & H) Error Mode: Misperception . (H) Safety Culture Analysis The safety culture analysis suggested that two aspects of safety culture should be investigated in more depth. 19th October 1998 Human Error Analysis Behaviour: A linesman. (H) Negative feedback when work is planned without T3 possession – negative. Ranskill. The analysis also suggested that communications relating to safety. immediate and certain consequences. (O) Familiarity with the task – the gang were expecting to apply short earths and they were less familiar with long earths – this could have affected the performance of all involved.) and expectation (Expect something to take place so strongly that you believe that it has occurred even if there is evidence to suggest otherwise) is most likely to have been the mechanism.Procedure to state specifically that this work should not be conducted when the conductor rail is energised or adequate safeguards are in place. 2 Issue 1. and the competence of personnel in safety should be examined in addition. immediate and certain consequence. Either the victim expected that his colleague would have removed the top clamp. providing those involved with positive. whilst disconnecting earths from an overhead line. (H) Required Consequences: Avoid injury to self or others. immediate and certain consequence. (H) Provide negative feedback on any risk assessments that focus on hazards rather than risks – providing those involved with negative. (H) Audit risk assessments and positive feedback on well-documented risk assessment. removed the earth end before the live end. resulting in fatal electric shock. or he would have been unable to see clearly in the dark. Performance-Shaping Factors: Communication quality – the communication on progress of the job was poor and could have affected the performance of all team members. the extent to which productivity or safety come first. immediate and certain consequence. or other type of loss or damage – positive. (O) Lighting – the fact that the task was being conducted in the dark with task lighting may have greatly affected performance.Mistakenly perceived that the live end of the earth had been removed by his colleague. Page 107 of 127 . immediate and certain consequences of noncompliance.
Alertness. (H) Tollerton. an uninsulated spanner made contact with the conductor rail. (O & H) Error Mode: Selection error . causing ignition of grease and injury to two workers.Tool unintentionally made contact with the energised conductor rail. (H) Error Mechanism: Human variability . leading to contact with live OHLE. (O) Consequences: Cause injury to self or others.Temporary lack of precision. immediate and certain consequence of the behaviour. 2 Issue 1. (O) Alertness / concentration / fatigue – Assumption: it is possible that such factors caused a lapse in concentration.The crane driver’s colleague did not intervene. (H) Performance-Shaping Factors: Equipment ergonomics – the equipment was not insulated against electricity. (H) Save time – Assumption: it is possible that the crane operator was trying to save some time. (H) Team co-ordination quality – Assumption: the co-ordination of effort between members of the team could have affected the performance of all team members. Error Type: Action error . (H) Avoid ridicule from colleague for refusing to work without an isolation – a positive. (O & H) Team communication quality – communications within the team could have been more frequent and may have had an effect on team performance. (H) Desired Behaviour: Crane operators not to operate arm in proximity to live OLE. Page 108 of 127 . which would have been a positive. (O) Team co-ordination quality – the co-ordination effort within the team could have been better. and booked 84 hours per week for the previous two weeks. Required Triggers: Audit of operations around OLE (H) COSS to remain with work party throughout operation (H) Report No.COSS expectations were not made clear to the crane operator (O & H) Other people’s example . 10th October 2001 Human Error Analysis Behaviour: Whilst maintaining a rail flange lubricator. would be seen as a negative. future and uncertain consequence. immediate and certain consequence from the point of view of the crane operator. (H) West Croydon. Triggers: Other people’s expectations . 2nd May 2001 ABC Analysis Behaviour: The crane operator raises the crane arm whilst unloading. concentration and fatigue – the victim had worked 21 consecutive shifts before the accident. or other type of loss or damage.Unintentionally positioned the spanner against the conductor rail.
future and certain consequence. or other type of loss or damage. immediate and certain. 2 Issue 1. a negative. positive.Required Consequences: Avoid injury to self or others. a positive. immediate and certain from those involved. Page 109 of 127 . (H) Receive reprimand for poor work planning. (H) Negative feedback when work is planned without T3 possession – a negative. future and certain consequence. (H) Receive positive feedback for well-done method statements and risk assessments – to be seen as positive. (H) Report No. (H) Positive feedback when work has been planned for T3 possession. future and certain consequence to discourage undesired behaviour.
2 Issue 1. Page 110 of 127 .Appendix E Task Lists for Predictive Human Error Analysis Inspection and Servicing Tasks Contact and catenary geometry inspection (crucifix gauge) Inspection of aerial feeds and jumpers (included in EO1) Bond testing (critical bonding) Contact and catenary geometry inspection (ultrasonic gauge) Booster inspection Vegetation survey transformer Contact and catenary geometry inspection (laser gauge) Inspection of traction earthing and bonding (included in EO1) Inspection and maintenance Tasks Inspection of conductor Rail Inspection of cables Catchpit clearance Patrolling (Risk only from con rail) Structures inspection only from con rail) (Risk Inspection of fastenings Inspection of continuity bonds Switch heater maintenance monthly checks (Risk only from con rail) S & C inspections (Risk only from con rail) Vegetation clearance using flail mower mounted on 'on track' machine Ultrasonic inspection (manual) with hand trolley (Risk only from con rail) Inspection of insulators Inspection of conductor rail equipment protection boarding Maintenance of ballast retention devices (Risk only from con rail) Formation inspection (Risk only from con rail) Vegetation clearance using manual methods Surveying using levelling equipment (Only risk from Con Rail) Longitudinal timbers inspection (Risk only from con rail) Maintenance Tasks Maintenance of rails Maintenance of cables Removal and replacement of cables and tamper proof tubing from underneath rails Profile gauging of conductor rail Changing traction negative bonds Replacing conductor rail Tapping of pre-drilled holes in conductor rail to facilitate the connection of fittings Tripping of circuit breaker using short-circuiting bar Maintenance of switches and isolators Rail lubricator replacement (Risk only from con rail) CWR stress management (Risk only from con rail) CWR transpose Rail welding (MMA) Maintenance of fastenings Maintenance of continuity bonds Fitting cables of terminations to Maintenance of insulators Maintenance of conductor rail protection boarding Drilling of running rail Painting ramp ends Applying conductor rail wraps Fitting attachments to conductor rail Fitting and removal of conductor rail short-circuiting device Fitting arc control shield Rail lubricator servicing (Risk only from con rail) Rail adjusting (Risk only from con rail) Restressing (elimination of non-compliances) (Risk only from con rail) Rail welding (thermic) (Risk only from con rail) Adjustment switch maintenance (Risk only from con rail) Spatial gauging of conductor rail Changing insulator pots Cutting and conductor rail Hookswitch changing Install glass-fibre shrouding under conductor rail Maintenance of cathodic protection systems Fishplate oiling (Risk only from con rail) Drilling conductor rail CWR Renewal Adjustment replacement switch welding Report No.
Rail changing (wear) IBJ maintenance (Risk only from con rail) Rail grinding (RMMM/RRV) Replacement of pads and nylons (Risk only from con rail) Longitudinal timber renewal Dynamic gauge maintenance (Risk only from con rail) manual stone blowing (Risk only from con rail) Ballast unloading / levelling from on top of a wagon Eradication of wet beds (manual) (Risk only from con rail) Renewals (reballasting or formation work) Retimbering (Risk only from con rail) Switch heater maintenance annual check (Risk only from con rail) Drainage clearance (highpressure water jetting) Catchpit maintenance Culvert maintenance (<450mm) Litter.g. Page 111 of 127 . wind-blown debris) Insulator cleaning Power maintenance Maintenance notices transformer of warning Isolator switch maintenance Maintenance of access ladders Maintenance of guard rails Dropper replacement Neutral section spreader bar replacement Dunted insulator renewal Maintenance of monitoring equipment wind Maintenance of platforms Bow wire anchor renewal Damaged area rectification (contact wire by tension length and droppers) GN Area butyl rubber insulator renewal Panchex maintenance (servo adjustments) Report No. spoil and debris clearance (inside stations) Point machine / mechanism replacement Maintenance of level crossing CCTV and supports (fixed) Equipment housings replacement Inspect and maintain overhead line (EO2) Neutral section maintenance Maintenance of aerial feeds and jumpers (included in EO2) Longitudinal timber and fastening maintenance (Risk only from con rail) Complete resleepering stone blowing using vehicle (Risk only from con rail) Ballast profiling (Risk only from con rail) Eradication of wet beds using on-track plant S&C tamping (Risk only from con rail) Manual maintenance of S&C (Risk only from con rail) Renewals Ditch clearance Drainage maintenance Culvert (<450mm) repair and renewal Ultrasonic inspection (manual) using hand probe (Risk only from con rail) Level crossing equipment renewal Renewal of level crossing equipment Interlocking equipment replacement Removal of object from OLE (e. 2 Issue 1. spoil and debris clearance (outside stations) Signals renewal Maintenance of height restriction devices Signal control equipment replacement Maintenance of OLE in tunnels Section insulator maintenance Booster transformer maintenance Maintenance of mechanical barriers Maintenance of climbing equipment Painting of structures Localised contact wire renewal (circa 10 metre lengths) GN area bonding renewal (drilled and bolted) Panchex maintenance (changing potentiometers) Rail changing (defective) Check rail changing (Risk only from con rail) Rail grinding (trolley) Changing fastenings only from con rail) (Risk IBJ renewal Guard rail maintenance (Risk only from con rail) Spot resleepering Sleeper retention device maintenance (Risk only from con rail) Direct fastening maintenance (Risk only from con rail) Plain line tamping (Risk only from con rail) Manual correction to PL track geometry (Risk only from con rail) Maintenance of free-draining ballast and formation (Risk only from con rail) Maintenance of clearances (Risk only from con rail) S&C Unit renewal (half-set switches or Xing) Electrical arc weld repairs Drainage clearance (manual rodding using long rods) Culvert clearance (all diameters) Ditch maintenance Litter.
DC 11kV / 750V DC transformer rectifier maintenance Outstation supervisory remote control Inspection. Page 112 of 127 . intrusive and nonintrusive maintenance of NCL LV CB / Panel maintenance Battery system maintenance (free vent) Harmonic filter maintenance Supervisory cable testing and maintenance Motorised switch maintenance Main and standby supplies maintenance 415V SSP UPS maintenance Maintenance of radio masts Lineside cable renewals Maintenance of elevated cable routes Oil pumping HV cables Straight post replacement Painting signal structures Maintenance of lighting (fixed) Maintenance of structure and fabric of sub stations Maintenance of structure and fabric of TP huts Inspection. guard rails. intrusive and nonintrusive maintenance of HVCB SMOS Painting of support structures Communications cable renewals Hookswitch operation Roof work location cases/superlocs Brackets / gantry maintenance Inspection. intrusive and nonintrusive maintenance of HSCB maintenance in sub station and TP hut Inspection. intrusive and nonintrusive maintenance of NCL 11kV OCB maintenance Inspection. 2 Issue 1. intrusive and nonintrusive maintenance of Voltage regulator 650V mobile maintenance Inspection. intrusive and nonintrusive maintenance of HVCB in sub station (VCBs) Renewals of ladders.roof repairs relay Brackets / gantry replacement Report No. Signalling cable renewals Renewal of troughing units Location cases and rooms . intrusive and nonintrusive maintenance of traction derived supply point (supply changeover test) Protection testing NCL Transformer maintenance (11kV / 440V) Control room supervisory remote control Inspection.Replacement plastic dropper sleeves with stainless steel Crossed contact assemblies bridge High speed stirrups steady arm Dropper saddles Catchpit clearance (mechanised) using on track plant Maintenance of structure and fabric of relay rooms Driver only operation mirrors and heaters maintenance Maintenance of structure and fabric of equipment rooms Inspection. intrusive and nonintrusive maintenance of SSP / Aux. HV transformer LV wiring certification testing and Maintenance of lineside signs Maintenance of noise reduction barriers Driver only operation platform CCTV maintenance Radio antennae (track side) Inspection. etc. intrusive and nonintrusive maintenance of 11kV 3ph AC non traction substation Battery system maintenance (VRLA) Protection testing . intrusive and nonintrusive maintenance of NCL frame leakage testing Inspection.
repositioning coming into contact new rail. trained and competent staff Probable Isolation Site specific method statements. 2 Issue 1. trained and competent staff Probable Isolation Site specific method statements. Page 113 of 127 . trained and competent staff Compliance with relevant Engineering Acceptance Standards required. disposal of old rail. Where tasks indicate an unacceptable risk then appropriate control measures should be developed to bring the residual risk down to a tolerable level Report No. trained and competent staff Probable Isolation Site specific method statements. with live OLE Rail grinding using On Track On and off tracking of Plant machine Rail grinding using hand On/off loading from trolley vehicle Equipment/materials Major renewal activity coming into contact with live OLE Equipment/materials Major renewal activity coming into contact with live OLE Equipment/materials Staff stood on wagon coming into contact unloading/levelling ballast with live OLE Eradication of wet beds (using on track Wet spot eradication using On On and off tracking of plant) Track Plant machine Renewals (reballasting or formation work) S&C unit renewal (half-set switches or Xing) Renewals Major renewal activity Major renewal activity Major renewal activity Equipment/materials coming into contact with live OLE Equipment/materials coming into contact with live OLE Equipment/materials coming into contact with live OLE Note: The possible mitigations are for consideration only.75M <600mm 2. PPE Probable Isolation Site specific method statements. trained and competent staff Possible Isolation Site specific method statements.Appendix F1 Task List and Risk Assessment for Permanent Way Engineering in OLE Area Showing Red Risks Proximity to OLE Task Description Key Electrical Risk 600mm >2. trained and competent staff Probable Isolation Site specific method statements. trained and competent staff Probable Isolation Site specific method statements. trained and competent staff. Suitable Equipment. trained and competent staff S 5 5 5 5 5 5 5 5 5 5 5 5 Total 20 15 15 15 15 20 20 20 15 20 20 20 Surveying using levelling equipment CWR transpose CWR renewal Rail grinding (RMMM/RRV) Rail Grinding (Trolley) Longitudinal timber renewal Complete resleepering Ballast unloading/levelling (manual) Staff undertaking optical survey of track Cutting of rails and turning them Equipment coming into contact with live OLE Equipment/materials coming into contact with live OLE Laying out of new rail. Equipment/materials cutting old rail. trained and competent staff Probable Isolation Site specific method statements. trained and competent staff Probable Isolation Site specific method statements. Site specific method statements.75M RA Basic Control Measures L 4 3 3 3 3 4 4 4 3 4 4 4 Possible Mitigations Possible Isolation Site-specific method statements.
trained and competent staff.75M 4 S 5 Total 20 Site-specific method statements. trained and competent staff Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Signal sighting checks (New) Location cases and Relay Rooms .2.75M <600mm L .Appendix F2 Task List and Risk Assessment for Signalling Engineering in OLE Area Showing Red Risks Proximity to OLE RA Basic Control Measures Task Description Key Electrical Risk Equipment could come into contact with live OLE Persons and Equipment coming into contact with live OLE Ditto Ditto Ditto Ditto Ditto Plant & Equipment could come into contact with live OLE Persons and Equipment coming into contact with live OLE Plant & Equipment could come into contact with live OLE Ditto Ditto Ditto Possible Mitigations 600mm >2. PPE Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Possible Isolation Site specific method statements.Roof Repairs Roof Work location cases/superlocs Straight Post replacement Brackets/Gantries replacement Brackets/Gantries maintenance Painting Signal Structures (all) Point Machine/Mechanism replacement Site specific from ground could use periscope 5 5 5 5 5 5 4 5 5 5 5 5 5 5 25 25 25 25 25 25 20 Renewal Activity Renewal Activity Intrusive Maintenance Renewal Activity Renewal Activity/Ground Mounted Renewal Activity Renewal Activity/Ground Mounted Site Specific Replacement Site Specific Replacement Site Specific Replacement Signals Level Crossing equipment Equipment Housings Interlocking equipment Signal Control Equipment 5 4 4 4 4 5 5 5 5 5 25 20 20 20 20 Note: The possible mitigations are for consideration only. Suitable Equipment. 2 Issue 1. Page 114 of 127 . Report No. Where tasks indicate an unacceptable risk then appropriate control measures should be developed to bring the residual risk down to a tolerable level.
Page 115 of 127 . trained and competent staff Could require isolation dependent on cable routing Could require isolation dependent on cable routing Could require isolation dependent on cable routing Could require isolation dependent on cable routing Could require isolation dependent on cable routing S 5 5 5 5 5 5 Total 20 20 20 20 20 20 Radio Antennae (Track Side) Lineside cables renewals Signalling cable renewals Communications cables renewals Maintenance of cable routes Renewal of troughing units Maintain or Replace Ground Equipment Site Specific Site Specific Elevated Elevated Note: The possible mitigations are for consideration only.75M Task Description RA Basic Control Measures 600mm <600mm L .2. 2 Issue 1.Appendix F3 Task List and Risk Assessment for Telecommunications Engineering in OLE Area Showing Red Risks Key Electrical Risk Plant & Equipment could come into contact with live OLE Plant & Equipment could come into contact with live OLE Plant & Equipment could come into contact with live OLE Plant & Equipment could come into contact with live OLE Plant & Equipment could come into contact with live OLE Plant & Equipment could come into contact with live OLE Proximity to OLE >2.75M 4 4 4 4 4 4 Possible Mitigations Possible Isolation Site specific method statements. Where tasks indicate an unacceptable risk then appropriate control measures should be developed to bring the residual risk down to a tolerable level Report No.
trained and competent staff Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Intrusive maintenance of the OLE system Intrusive maintenance of the Section Insulator Maintenance OLE system Intrusive maintenance of the Insulator Cleaning OLE system Maintenance of Aerial Feeds and Intrusive maintenance of the Jumpers (Included in EO2) OLE system Intrusive maintenance of the Booster Transformer Maintenance OLE system Intrusive maintenance of the Isolator Switch Maintenance OLE system Intrusive maintenance near to Maintenance of Mechanical Barriers the OLE system Intrusive maintenance near to Maintenance of Access Ladders the OLE system Intrusive maintenance near to Maintenance of Climbing Equipment the OLE system Intrusive maintenance near to Maintenance of Platforms the OLE system Intrusive activity near to live Painting of Structures OLE equipment Intrusive activity on or near to Bow Wire Anchor Renewal live OLE equipment Intrusive activity on or near to Dropper Replacement live OLE equipment Localised Contact Wire Renewal (Circa Intrusive activity on or near to 10 Metre Lengths) live OLE equipment Damaged Area Rectification (Contact Intrusive activity on or near to Wire by Tension Length + Droppers) live OLE equipment Report No.75M Inspect and Maintain Overhead Line (EO2) Maintenance of OHLE in Tunnels Removal of object from OLE Neutral Section Maintenance Intrusive maintenance of the OLE system Intrusive maintenance of the OLE system Staff removing objects e. wind blown debris from OLE Staff or equipment coming into contact with live equipment Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto RA Basic Control Measures L 5 5 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 600mm <600mm 2.75M Possible Mitigations S 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Total 25 25 20 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 Isolation Required Isolation Required Possible Isolation Site specific method statements. Page 116 of 127 .g.Appendix F4 Task List and Risk Assessment for Contact Systems Engineering in OLE Area Showing Red Risks Proximity to OLE Task Description Key Electrical Risk >2. 2 Issue 1.
75M Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto RA Basic Control Measures L 5 5 5 5 5 5 5 5 5 5 5 600mm <600mm 2. Page 117 of 127 .75M Possible Mitigations S 5 5 5 5 5 5 5 5 5 5 5 Total 25 25 25 25 25 25 25 25 25 25 25 Isolation Required Possible Isolation Site specific method statements.Proximity to OLE Task Neutral Section Spreader Bar Replacement Bonding Renewal (Drilled and Bolted) Butyl Rubber Insulator Renewal Dunted Insulator Renewal Panchex Maintenance (Changing Potentiometers) Panchex Maintenance (Servo Adjustments) Maintenance of Wind Monitoring Equipment Description Intrusive activity on or near to live OLE equipment Intrusive activity on or near to live OLE equipment Intrusive activity on or near to live OLE equipment Intrusive activity on or near to live OLE equipment Intrusive activity on or near to live OLE equipment Intrusive activity on or near to live OLE equipment Intrusive activity on or near to live OLE equipment Key Electrical Risk >2. trained and competent staff Isolation Required Isolation Required Isolation Required Isolation Required Replacement of Plastic Dropper Sleeves Intrusive activity on or near to with Stainless Steel live OLE equipment Intrusive activity on or near to High Speed Steady arm Stirrups live OLE equipment Intrusive activity on or near to Dropper Saddles live OLE equipment Intrusive activity on or near to Cross Contact Bridge Assemblies live OLE equipment Note: The possible mitigations are for consideration only. Report No. Where tasks indicate an unacceptable risk then appropriate control measures should be developed to bring the residual risk down to a tolerable level. trained and competent staff Isolation Required Isolation Required Isolation Required Isolation Required Possible Isolation Site specific method statements. 2 Issue 1.
Task List and Risk Assessment for Power Distribution Engineering in OLE Area Showing Red Risks
Proximity to OLE Task Description Key Electrical Risk >2.75M
HVCB maintenance SMOS Inspection, non-intrusive and intrusive maintenance Inspection, non-intrusive and intrusive maintenance Inspection, non-intrusive and intrusive maintenance Inspection, non-intrusive and intrusive maintenance Inspection, non-intrusive and intrusive maintenance Electrocution
RA Basic Control Measures L
600mm <600mm 2.75M
Site-specific method statements, trained and competent staff. Certificated in accordance with NR standards. Permit to Work System. Management of Interface with Overhead line teams Site-specific method statements, trained and competent staff. Certificated in accordance with NR standards. Permit to Work System Site-specific method statements, trained and competent staff. Certificated in accordance with NR standards Site-specific method statements, trained and competent staff. Certificated in accordance with NR standards Site-specific method statements, trained and competent staff. Certificated in accordance with NR standards
Booster Transformer Maintenance Main & Standby Supplies Maintenance 650V Mobile maintenance 415v SSP UPS Maintenance
Electrocution Electrocution Electrocution Electrocution N/A N/A N/A N/A N/A N/A N/A N/A N/A
4 3 3 3
5 5 5 5
20 20 20 20
Note: The possible mitigations are for consideration only. Where tasks indicate an unacceptable risk then appropriate control measures should be developed to bring the residual risk down to a tolerable level
Report No. 2
Page 118 of 127
Task List and Risk Assessment for Off Track Activities in OLE Area Showing Red Risks
Proximity to OLE Task Description Key Electrical Risk >2.75M
Maintenance of fencing-Chain links Maintenance of the railway boundary Staff or equipment coming into contact with live OLE Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto
RA Basic Control Measures L
3 3 3 3 3 3 3 3 3 4 3 3 3 3 4 3 3 3 3 3 3
600mm <600mm 2.75M
Safe System of work required to ensure staff or equipment do not come with 2.75 metres. Use of trained and competent staff Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Possible Isolation Required Possible Isolation Required Possible Isolation Required Could require isolation when working on roof Could require isolation when working on roof Could require isolation when working on roof Could require isolation when working on roof
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
15 15 15 15 15 15 15 15 15 20 15 15 15 15 20 15 15 15 15 15 15
Maintenance of fencing - Palisade Ditto Maintenance of fencing - Post and wire Ditto Maintenance of Boundary Walls Ditto Maintenance of Retaining Walls <1m Ditto high Maintenance of Retaining Walls provided for location of Signalling or electrical Ditto equipment Maintenance of Level Crossing CCTV Staff working at high level and supports (fixed) Maintenance of noise Maintenance of noise reduction barriers reduction barriers Maintenance of height restriction devices Ditto Renewal of Level Crossing Equipment Lineside signs Drainage clearance (manual rodding) Major renewal activity
Staff working at high level Ditto Staff using long rods Ditto Catch pit clearance using On On and off tracking of Catchpit clearance (mechanised) Track Plant machine Maintenance of lighting (fixed) Staff working at high level Ditto Drainage clearance (high pressure water High pressure water jet Fine water spray on live jetting) machine OLE causing tracking Cutting back of lineside Vegetation clearance using flail mower vegetation using "on track" Ditto mounted on "on track" machine machine Vegetation clearance using manual Cutting back of lineside Ditto methods vegetation using hand tools Relay Rooms Building maintenance work Ditto Sub Stations Building maintenance work Ditto TP Huts Building maintenance work Ditto Equipment Rooms Building maintenance work Ditto
Note: The possible mitigations are for consideration only. Where tasks indicate an unacceptable risk then appropriate control measures should be developed to bring the residual risk down to a tolerable level.
Report No. 2
Page 119 of 127
Task List and Risk Assessment for Permanent Way Engineering in DC Conductor Rail Area Showing Red Risks
Task Ultrasonic Inspection (Manual) Surveying using levelling equipment Rail lubricator servicing Rail lubricator replacement Fishplate oiling Rail adjusting CWR stress management Restressing CWR transpose CWR renewal Rail welding (Thermic) Rail Welding (MMA) Adjustment switch replacement Adjustment switch maintenance Rail changing (wear) Rail changing (defective) IBJ renewal IBJ maintenance Check rail changing Guard rail maintenance Rail grinding (In train) Rail Grinding (Trolley) Spot resleepering Replacement of pads and nylons Description Staff undertaking NDT using hand probe Staff undertaking optical survey of track Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Cutting of rails and turning them Laying out of new rail, cutting old rail, repositioning new rail, disposal of old rail. Staff working at rail level Staff working at rail level Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Tightening of fastenings Rail grinding using vehicle in train formation Rail grinding using hand trolley Staff working at rail level Staff working at rail level Key Electrical Risk Staff or equipment coming into contact with live con rail Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Electric Shock due to earthing arrangement Staff or equipment coming into contact with live con rail Ditto Ditto Ditto Ditto Ditto Ditto Ditto None Identified On/off loading from vehicle Manual Handling of sleeper and equipment in close proximity to live rail Staff using hand tools in close proximity to live rail Proximity to Basic Control Measures Conductor Rail >300 mm < 300mm L S Total 4 4 4 4 4 4 5 5 5 5 4 4 5 5 5 5 5 4 5 3 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 20 20 20 20 20 20 25 25 25 25 20 20 25 25 25 25 25 20 25 15 25 25 25 25
Site-specific method statements, trained and competent staff. Use of PPE & Insulated Tools Ditto Possible Isolation Site-specific method statements, trained and competent staff. Use of PPE & Insulated Tools Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto
Report No. 2
Page 120 of 127
Task Changing fastenings Sleeper retention device maintenance Longitudinal timber renewal Longitudinal timber & fastening maintenance Direct fastening maintenance Dynamic gauge maintenance Complete resleepering Stoneblowing Manual correction to PL track geometry Eradication of wet beds (manual) Eradication of wet beds (using on track plant) Maintenance of clearances Renewals (reballasting or formation work) S&C unit renewal (half-set switches or Xing) Retimbering Manual maintenance of S&C Electric arc weld repairs Switch heater maintenance annual check Renewals Description Staff working at rail level Staff working at rail level Major renewal activity Staff working at rail level Staff working at rail level Staff working at rail level Major renewal activity Stone blowing using manual methods Measured Shovel Packing/Kango Packing Staff working at rail level Wet spot eradication using On Track Plant Staff undertaking track slews Major Renewal Activity Major renewal activity Renewal Activity Measured Shovel Packing/Kango Packing Staff working at rail level Intrusive Maintenance Major renewal activity Key Electrical Risk Ditto Ditto Equipment/materials coming into contact with live con rail Staff using hand tools in close proximity to live rail Ditto Ditto Equipment/materials coming into contact with live con rail Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Proximity to Basic Control Measures Conductor Rail >300 mm < 300mm L S Total 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 20 25 25 Possible Mitigations Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Note: The possible mitigations are for consideration only. 2 Issue 1. Report No. Page 121 of 127 . Where tasks indicate an unacceptable risk then appropriate control measures should be developed to bring the residual risk down to a tolerable level.
service TCAID .service Detonator placers . TPWS Track Circuit .service Mechanical detector .service HABD maintenance Wheel flat detection maintenance 3rd rail shoegear detection maintenance Automatic trainstop protection Dragging brake maintenance gear detector Ditto Ditto Ground Mounted Ground Mounted Ground Mounted Ground Mounted Ground Mounted Ground Mounted Ground Mounted Ground Mounted Ground Mounted Ground Mounted 3 3 3 3 3 4 4 3 3 3 3 3 3 5 5 5 5 5 5 5 5 5 5 5 5 5 15 15 15 15 15 20 20 15 15 15 15 15 15 Note: The possible mitigations are for consideration only.Ditto service Electrical detector . trained competent staff.annual service Treadle . 2 Issue 1. Where tasks indicate an unacceptable risk then appropriate control measures should be developed to bring the residual risk down to a tolerable level. Use of PPE & Insulated Tools Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Total 15 and Facing point lock test Staff working at Rail Level Staff or equipment coming into contact with Con rail Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Point mechanism (all types inc back drives and supplementary detectors) .12 week service AWS. Report No. Page 122 of 127 .Task List and Risk Assessment for Signalling Engineering in DC Conductor Rail Area Showing Red Risks Proximity to Conductor Rail >300 mm < L 300mm 3 Appendix F8 Task Description Key Electrical Risk Basic Control Measures S 5 Possible Mitigations Possible Isolation Site-specific method statements.
Appendix F9 Task List and Risk Assessment for Contact Systems Engineering in DC Conductor Rail Area Showing Red Risks Proximity to Conductor Rail >300 < mm 300mm Basic Control Measures L 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Task Description Key Electrical Risk Staff or equipment coming into contact with live con rail Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Possible Mitigations S 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Total 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Safe System of Work required. development of new non contact gauge Ditto Isolation Required Safe System of Work required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Isolation Required Potential for Maintenance of Rails Maintenance of Fastenings Maintenance of Insulators Maintenance of Cables Maintenance of Continuity Bonds Maintenance of Conductor Rail Equipment Protection Boarding Removal and replacement of cables and tamper proof tubing from underneath rails Fitting of terminations to cables Drilling Conductor Rail Drilling of running rail Profile Gauging of Conductor Rail Spatial Gauging of Conductor Rail Painting Ramp Ends Changing Traction negative bonds Changing Insulator Pots Applying Conductor Rail Wraps Replacing Conductor Rail Cutting and Welding Conductor Rail Fitting Attachments to Conductor Rail Tapping of pre drilled holes in conductor rail to facilitate the connection of fittings Hookswitch Changing Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Crimping cables using hydraulic crimping tool Intrusive maintenance Intrusive maintenance Profile gauging using insulated gauge Spatial gauging using insulated gauge Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Intrusive maintenance Report No. Page 123 of 127 . 2 Issue 1.
2 Issue 1. Report No.Task Fitting and Removal of Third Rail Short Circuiting Device Tripping of Circuit Breaker using short circuiting bar Install glass fibre shrouding under conductor rail Fitting Arc Control Shield Tunnel Patrol Maintenance of Switches and Isolators Maintenance of Cathodic Protection Systems Description Key Electrical Risk Proximity to Conductor Rail >300 < mm 300mm Basic Control Measures L 4 4 Possible Mitigations S 5 5 Total 20 20 Undertake task in accordance with GO/RT 3091 Undertake task in accordance with GO/RT 3091 Isolation Required Isolation Procedures Isolation Procedures Intrusive maintenance Intrusive maintenance Foot Patrol and Visual Inspection of the P Way Intrusive maintenance Intrusive maintenance Ditto Ditto Ditto Ditto Ditto Ditto Ditto 4 3 4 4 5 5 5 5 20 15 20 20 Isolation Required All staff undertaking these tasks have been trained and certificated to PTS requirements Safe System of Work required Safe System of Work required Note: The possible mitigations are for consideration only. Page 124 of 127 . Where tasks indicate an unacceptable risk then appropriate control measures should be developed to bring the residual risk down to a tolerable level.
Where tasks indicate an unacceptable risk then appropriate control measures should be developed to bring the residual risk down to a tolerable level Report No. Page 125 of 127 .Appendix F10 Task List and Risk Assessment for Off Track Activities in DC Conductor Rail Area Showing Red Risks Proximity to Conductor Rail Task Description Key Electrical Risk Basic Control Measures S 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Possible Mitigations >300 < L mm 300mm 3 3 3 4 4 3 3 3 3 3 3 3 3 3 Total 15 15 15 20 20 15 15 15 15 15 15 15 15 15 On/Off tracking needs to be considered Safe System of Work required to ensure activity is kept more than 300mm away from Con Rail Activity is away from live con rail Possible Isolation required Possible Isolation required Safe System of Work required to ensure activity is kept more than 300mm away from Con Rail Safe System of Work required to ensure activity is kept more than 300mm away from Con Rail Safe System of Work required to ensure activity is kept more than 300mm away from Con Rail Safe System of Work required to ensure activity is kept more than 300mm away from Con Rail Safe System of Work required to ensure activity is kept more than 300mm away from Con Rail Safe System of Work required to ensure activity is kept more than 300mm away from Con Rail Safe System of Work required to ensure activity is kept more than 300mm away from Con Rail Safe System of Work required to ensure activity is kept more than 300mm away from Con Rail Safe System of Work required to ensure activity is kept more than 300mm away from Con Rail Vegetation clearance using flail Cutting back of lineside vegetation mower mounted on "on track" using "on track" machine machine Vegetation clearance using manual Cutting back of lineside vegetation methods using hand tools Survey undertaken by staff from Vegetation Survey Cess or foot patrol from track Drainage clearance (manual Staff using long rods rodding) Drainage clearance (high pressure High pressure water jet machine water jetting) Ditch clearance Culvert clearance (all diameters) Catchpit maintenance Drainage maintenance Ditch maintenance Culvert maintenance (<450mm) ditto but for repair and renewal Litter. Spoil and Debris Clearance (inside stations) Litter. Spoil and Debris Clearance (outside stations) Staff Working at Rail Level Staff Working at Rail Level Staff Working at Rail Level Staff Working at Rail Level Staff Working at Rail Level Staff Working at Rail Level Staff Working at Rail Level Staff Working at Rail Level Staff Working at Rail Level Staff or equipment coming into contact with live con rail Ditto Staff or equipment coming into contact with live con rail Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Staff or equipment coming into contact with live con rail Note: The possible mitigations are for consideration only. 2 Issue 1.
2 Issue 1. Page 126 of 127 .This page is intentionally blank Report No.
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