Summary
At 13:50 hrs on Tuesday 4 December 2012, a train travelling from Scunthorpe
to Lincoln struck and fatally injured a track worker at Saxilby, near Lincoln. The
individual concerned was acting in the role of Controller of Site Safety (COSS) at the
time of the accident. He was involved in work taking place onQ one of the two tracks
at this location which was closed to rail traffic, but standing close to the adjacent line
over which trains were still operating.
The RAIB’s investigation found that the COSS stepped back into the path of the train
as it passed the site of work. The following factors led to the accident:
- the COSS had not implemented a safe system of work for the task that was being
- undertaken at the time that the accident occurred;
- none of the other track workers on site challenged the absence of a safe system of
- work or the actions of the COSS who was working within an unsafe area;
- the COSS became distracted and did not see or hear the approaching train;
- no effective action had been taken in response to the involvement of the COSS in
- two other safety incidents in the two months preceding the accident;
- the COSS had not been subject to an effective formal performance review by the
- agency (SkyBlue) that had hired him for COSS duties for the work taking place on
- December 2012 and on other occasions; and
- deficiencies and omissions within SkyBlue’s management systems had not been identified by its parent company (Carillion).
The RAIB has also observed that the processes employed by the railway industry
during its own investigation into the accident at Saxilby may have taken insufficient
account of the trauma that some of the witnesses were suffering as a result of their
proximity to the accident.
The RAIB has made four recommendations. Three recommendations have been
made to Network Rail regarding the use of agency staff in safety leadership roles,
measures to address the risk arising from the use of agency staff in any role that
involves working on and around the track and its processes for interviewing witnesses
after serious incidents and accidents. One recommendation has been made to
Carillion in conjunction with SkyBlue in respect of reviewing the effectiveness of
changes made to safety management arrangements following the accident at Saxilby
