SCENARIO
RailStart (RS) is a private organisation overseen by the Government. It looks after track and signalling for the railway network in four regions across the country. These are the North, East, South, and West. RS must make sure that rail tracks are properly maintained, and that signalling meets the highest safety standards in these regions. RS has four operational offices across the country. They employ a range of workers, from technicians and customer service operatives to project engineers. RS also works with contractors, selected from a pre-approved contractors’ database.
The TrainDetect system
A new train safety system, called TrainDetect, has been developed which alerts train drivers to the presence of another train ahead of them on the same track. The system works by sensing the variations in voltage across the tracks when a train is present and when it is not. This mirrors the way that modern signalling works, and therefore requires minor changes to the existing infrastructure. RS are looking to incorporate the new TrainDetect system into their existing signalling infrastructure. However, it will require the replacement of the existing wiring with new wiring. This is fortunate for RS as much of the network’s existing wiring is decades-old and has become unreliable. Therefore, RS commits to a project to replace all the wiring on the network and to install the TrainDetect system across all four regions. As there is no single contractor with enough resources to carry out this work in the required timeframe, RS must work with multiple contractors across the country. Each contractor will work within a tightly defined, and pre-agreed, area of the network.
South region
One area of RS’s rail network has eight mainline approaches into a large city in the South region. It includes a particularly busy commuter route. The last train station on this route is a large, 20-platform station where multiple railway tracks converge, before taking various routes into and around the city. During the busiest times, a train arrives and departs at the station every minute. On the approach to this station there is a visual light signal 300 metres south of the platforms. This is the last signal before the trains reach the platforms. It provides signallers with the opportunity to halt trains before they enter the station. Signalling for the South region, as with many other areas of the train network, takes place centrally, from a location over 50km away. Although the signal box (a small building containing levers and control equipment to operate railway signals) is only 100 metres north of the visual light signal, this particular box has been unoccupied for several decades. It is in a poor state of repair. The electrical wires and switches inside this signal box were installed in the 1950’s and contain many components made of substances that are now classed as a health hazard. The signal box has been repeatedly vandalised by people who have accessed the railway by breaking through fencing. Although RS has replaced the fencing many times, it has always used the same inexpensive type of fence. RS has not checked the fence condition for a long time. Warning signage has fallen off and broken. One of the consequences of the vandalism is that the lighting inside this signal box no longer works. Five years previously, a youth broke through the fencing and was nearly struck by a train.
Subsequently, RS was the subject of enforcement action.
The contractor
Contritum is a multi-discipline contractor with 10 years’ experience in railway work. The organisation has doubled in size in the last three years. It has a reputation for aggressively pursuing railway work and getting the work done on time or even earlier. The director of RS has recently attended some entertainment events as a guest of the Board of Contritum. At a recent event, the RS director discussed the TrainDetect project with the managing director of Contritum. The RS director was told that all Contritum workers are very experienced, producing quality work, and they have worked with Contritum for a long time. Based on accident data, the managing director of Contritum boasted that the organisation has a low number of recorded accidents compared to others in this industry. Impressed by their apparent strong health and safety values, the RS director decides to meet with the managing director of Contritum again. During this meeting they look at Contritum’s general risk assessment, method statements and site inspections for previous rail works. The RS director particularly likes the fact that Contritum use their own on-site supervisors to conduct their site safety inspections. The inspection results always seem to be to a high standard. The RS director thinks that this will save them time and resources because they will not have to conduct their own regular site inspections.
After the meeting, the RS director decides that Contritum are the contractor of choice for the TrainDetect work for the South region. They also award Contritum the maintenance contract for the region. This includes maintenance on level crossings, replacing lighting at stations, and repairing trackside fencing where it has been damaged or has rotted. Although Contritum are currently working on other projects and they have never worked on such a large-scale project before, they still accept the work for the South region.
The project
Work on the TrainDetect installation is being managed from the Contritum office by a project management team. This team consists of a senior engineer, an electrical engineer and three support workers. Between them they manage the installation of the TrainDetect system across the entire South region with as many as 10 teams of engineers working on-site simultaneously.
One of the teams consists of four site engineers overseen by an on-site supervisor. Three of these engineers have been with the organisation for 10 years and have seen its rapid growth. They are all in their late twenties and have been trained almost exclusively by Contritum. The fourth engineer (Engineer D), in their early fifties, joined the organisation three months ago. RS are unaware of any new recruits at Contritum. The amount of existing work that Contritum has, means that all workers have been continually asked to work overtime.
As the TrainDetect project is keeping everyone so busy, Engineer D has not been able to complete their induction training; however, they have done similar work for other organisations in the past. They have worked in a variety of trades, finally choosing to work in electrical engineering two years’ago. As they tell their friends, “It is not like other trades, it is mainly working indoors in the warm, so it is much better.”
The work
Three weeks into the project, some of the engineers have highlighted issues with their ability to physically access the relays (an electrically-operated switch) in the signal boxes. This is due to the age of the equipment and where it is positioned.
The old wiring is also proving difficult to remove, as it has become very brittle and is coated in thick dust; because of this, the senior engineer has decided that old wiring can be left in place, but should be properly insulated where it is exposed. A recent on-site inspection revealed that some old wiring left in place was not properly insulated. However, Contritum do not inform RS of these issues as they do not want to risk losing any work.
During this time, Contritum have noticed that RS does not seem to be aware of how frequently fencing is being damaged and replaced. As Contritum are always paid for the work, they do not tell RS that far stronger and more secure fencing options are available.
Four months into the project and the team have continuously worked six-day weeks. Some of the work must be carried out at night to minimise disruption to the train services into the city. The on-site supervisor and the team of four engineers begin their sixth consecutive night of work on the commuter line. The on-site supervisor is given the work plan from the project management team who only work during the day.
Tonight’s work involves some complicated rewiring at the signals and points (moveable sections on the track line), as well as a more straightforward task of rewiring equipment in the signal box.
The on-site supervisor is concerned, as the signal box task needs to be completed in one night and Engineer D has never done this particular task before. However, the on-site supervisor has not found anything wrong with Engineer D’s work so far, so they believe it will be safe. As the project management team are not working, the on-site supervisor is unable to change the work plan. Because there is so much work each night, the on-site supervisor is focused on checking more complicated work.
Engineer D
Once on site, Engineer D can see the lights of the large train station only 200 metres away. They confirm that the track is closed to trains. The on-site supervisor explains to Engineer D what needs to be done first in the signal box. All the wires to the relays on the lower shelves need to be replaced with the new wire. This will then be fed out through a duct to the signals and points along the track. Having explained this, the supervisor then takes the other three engineers to the various locations where the rest of the night’s work needs to be completed.
Engineer D enters the signal box and finds that the lights do not work. Undeterred, they wear a head torch to carry out the work. However, in the tight spaces behind the relays, they find that the head torch becomes restrictive. Although the rule is to always wear a head torch during night work, they decide to take off the head torch and use it as a hand torch. While working, Engineer D hears shouting and laughing nearby; in the distance they hear a police siren. Even though they are in the middle of rewiring, they go outside to see what is happening.
In the dim light they see someone climb through the broken fence towards the railway. They are clearly not wearing any reflective clothing. The person trips on the railway tracks, falls to the ground, and yells out in pain. Engineer D moves towards the injured person to help, and notices two police officers approaching. The police determine that the injured person has broken their ankle. The police arrest the person and call for an ambulance.
Engineer D speaks to the police and helps guide the paramedics to the injured person. An hour later, Engineer D returns to their work, upset by the event. They are now behind schedule with their work so they try to catch up. Despite the delay, cramped conditions, and accumulated dust everywhere in the signal box, Engineer D finishes all the rewiring on time. They are glad to finish work for the week and are looking forward to a day off. The on-site supervisor enters the signal box and asks if everything has been done. Engineer D explains about the earlier interruption and the on-site supervisor remarks, “Oh, people are always getting on to the railway tracks. I will have to report it again.” The on-site supervisor accepts Engineer D’s assurance that everything has been completed. They decide not to check the work because the railway lines are due to be open again soon.
The train crash
At 06:10, an early morning train approaches the signal box, where the work had been completed the night before. The train stops as the signal is set to red. At 06:12, a second train crashes into the stationary one ahead of it. Some carriages derail and the stationary train is shunted 50 metres along the track. The TrainDetect system has failed to alert the signalling centre or the train drivers that the trains are too close to each other on the same track.
The station workers see the dust rising from the crash site and immediately call the emergency services. Many people are injured on both trains.
On investigation, the TrainDetect system failure is traced back to one of the old wires that should have been removed by Engineer D. The wire was not bent back on itself and insulated, as per the job specification, causing a fault in the TrainDetect system.
Task 1: Role of health and safety in accident investigation
1 (a) What is the role of health and safety legislation in the workplace?
(b) The regional health and safety competent authority has investigated the events leading up to the person accessing the railway and becoming injured. On the basis of their findings, they decide to prosecute both
Contritum and RS using the principles of the ‘Enforcement Policy Statement’ (EPS) produced by the British Health and Safety Executive
(HSE).
Based on the following EPS principles, what will the competent authority have considered when deciding on this enforcement action?
(i) Proportionality.
(ii) Targeting.
Note: You should support your answers to (b) (i) and (b) (ii), where applicable, using relevant information from the scenario.
Task 2: Contractor management
2 (a) Comment on what was negative about the RS director’s approach to
contractor selection.
Note: You should support your answer, where applicable, using relevant information from the scenario.
(b) Comment on what was negative about the co-ordination between RS and
Contritum.
Note: You should support your answer, where applicable, using relevant information from the scenario.
Activity 1: Create an organisation risk profile of your chosen organisation
This section is very important. It describes the main risks that your organisation faces. The answers you give to the remaining activities in this paper must be consistent with the information you provide here (unless otherwise stated). For example, if the risks that you give here relate to the banking or insurance sectors, it would be unusual to later describe a situation where welding contractors are repairing a chemical storage tank in your own organisation.
1 The British Health and Safety Executive (HSE) has identified risk profiling as a core element for managing health and safety in their guidance document ‘Managing for Health and Safety’ (HSG65).
Produce a risk profile of your chosen organisation that outlines FOUR significant risks.
Note: You must use the Activity 1 format table provided in the answer sheet
to record your answers.
Health and safety legislation plays a pivotal role in mitigating risks, promoting safe work practices, and protecting both workers and the public in high-risk industries like railway management. The Health and Safety at Work Act (HSWA) 1974 is the cornerstone of workplace safety legislation in the UK. It places a general duty on employers to ensure the health, safety, and welfare of their employees and others affected by their work. The Management of Health and Safety at Work Regulations 1999 further requires employers to carry out risk assessments and implement appropriate measures to mitigate risks. In the context of RS and Contritum, both companies had clear legal responsibilities under these regulations. RS was responsible for ensuring the safety of the infrastructure it managed, particularly in the South region, where signal boxes and wiring were decades old and prone to failure. Contritum, as the contractor responsible for installing the TrainDetect system, was required to implement safe working practices and ensure that their workers adhered to safety standards. However, both organizations failed in their duty to protect workers and the public from foreseeable risks. The failure to replace outdated wiring, which was a contributing factor to the train crash, exemplifies a breach of both the HSWA and the Management Regulations. The scenario presents numerous examples of health and safety violations, starting with the neglected signal box that contained hazardous substances and outdated wiring. RS failed to ensure the box was in a fit state for workers, thus breaching the law's duty to provide a safe working environment. Similarly, Contritum’s negligence in inspecting and insulating old wiring represents a failure to follow safe work procedures, violating the legal requirement to mitigate risks to safety. Both RS and Contritum demonstrated significant lapses in complying with health and safety regulations, resulting in the train collision that injured numerous individuals. These failings underline the vital role that health and safety legislation should have played in preventing such incidents.
Proportionality is a guiding principle in the Health and Safety Executive’s (HSE) Enforcement Policy Statement (EPS), ensuring that enforcement actions correspond to the severity of the breach and the associated risks. The Enforcement Policy Statement (EPS) by the HSE outlines the principle of proportionality, which dictates that enforcement action should reflect the level of risk and the potential harm caused by non-compliance. This principle ensures that organizations face consequences aligned with the danger their failures present to workers and the public. In this case, the HSE would likely assess the proportionality of enforcement actions against RS and Contritum based on the severity of the health and safety breaches and their impact. RS's repeated failure to upgrade the fencing around the tracks, despite knowing that it was frequently vandalized, exposed the public to undue risk. This was further compounded by RS’s failure to address the dilapidated state of the signal box, a critical part of the railway infrastructure. For Contritum, the decision not to report issues with wiring insulation and to leave old wiring in place directly contributed to the system failure. These actions not only endangered workers but also led to a major accident that harmed many passengers. RS had already faced enforcement action five years prior after a youth narrowly escaped being hit by a train after breaching the weak fencing. This incident should have been a wake-up call to prioritize security and safety around the railway. Contritum, on the other hand, focused on completing the project on time, despite the clear safety risks associated with their decisions, including the lack of proper insulation of the old wiring. Given the high-risk environment and the resulting harm, proportional enforcement actions are justified against both RS and Contritum for their breaches of safety regulations. The severity of the train crash highlights the need for strong corrective measures to prevent future incidents.
The principle of targeting in the HSE’s EPS ensures that enforcement resources are directed at the most serious risks and breaches that are likely to cause significant harm. The targeting principle requires the HSE to focus enforcement efforts on the most severe and imminent risks, prioritizing areas where there is a high likelihood of harm. This approach ensures that organizations cannot ignore critical safety issues that pose a direct threat to workers and the public. In the case of RS and Contritum, the key risks centered around the poor condition of the signal box, the outdated wiring, and the inadequate fencing surrounding the railway tracks. These risks were well-known to both organizations, yet neither took sufficient action to address them. The targeting principle would guide the HSE to focus on these critical areas, ensuring that future enforcement actions prioritize addressing the fundamental safety failures that led to the accident. The broken fencing allowed individuals to access the railway tracks repeatedly, posing a direct threat to public safety. Additionally, the poor state of the signal box, with its faulty lighting and hazardous materials, created an unsafe working environment for engineers. These risks were known but not adequately targeted by RS or Contritum for remediation. The HSE’s targeting principle would likely focus on RS and Contritum’s failure to address the most serious risks in the workplace, which directly contributed to the train crash. Properly targeting these issues could have prevented the accident, underscoring the importance of focused enforcement.
The process by which RS selected Contritum as the contractor for the TrainDetect project was flawed, demonstrating a lack of due diligence and proper assessment of the contractor’s capacity to manage the project. Effective contractor selection is a critical component of project management, requiring organizations to conduct thorough evaluations of a contractor’s capabilities, experience, and safety performance. Contractor selection models emphasize the need for rigorous assessment of contractors' ability to handle the scale and complexity of a project, particularly in high-risk industries. RS’s decision to award Contritum the contract was influenced by social connections and surface-level impressions rather than a thorough evaluation of their capacity to undertake a large-scale project. The RS director’s decision was based on personal interactions at entertainment events and a superficial review of Contritum’s risk assessments and safety procedures. There was no evidence that RS critically evaluated Contritum’s ability to manage a project of this scale, nor did they consider the contractor’s capacity to safely complete the work under tight deadlines. Contritum had never undertaken a project of this magnitude before, and their workforce was already stretched thin with other ongoing projects. Moreover, RS was unaware that Contritum had recently hired new engineers, including Engineer D, who lacked sufficient training for the tasks at hand. This lack of oversight in the contractor selection process contributed directly to the safety failures that occurred during the project. RS’s approach to contractor selection was deeply flawed, as it prioritized personal relationships over a comprehensive assessment of Contritum’s qualifications. This failure to conduct proper due diligence had severe consequences for the project’s safety and success.
Poor coordination between RS and Contritum exacerbated the safety risks on-site and contributed to the system failures that ultimately led to the train collision. Effective communication and coordination between clients and contractors are essential for project success, especially in complex and high-risk projects. Project management theories emphasize the importance of clear communication channels, real-time updates, and collaborative decision-making to address risks and ensure safety. Throughout the TrainDetect project, there was a clear breakdown in communication between RS and Contritum. The on-site supervisors were often left to manage tasks without proper guidance from the project management team, particularly during night shifts. This lack of communication was evident when Engineer D encountered difficulties in the signal box but received no additional support. Furthermore, the decision to continue using outdated fencing without informing RS about better alternatives indicates a lack of transparency and coordination between the two organizations. The incident involving the trespasser on the railway tracks further highlights the coordination failures. While Engineer D was distracted by the emergency, there was no mechanism in place for them to communicate effectively with the project management team, leading to rushed and incomplete work in the signal box. Additionally, the on-site supervisor’s decision not to check Engineer D’s work demonstrates a lack of oversight and communication between Contritum’s team and RS’s safety management. The failure to establish effective communication and coordination between RS and Contritum significantly contributed to the safety lapses that led to the train crash. Improving these communication processes would have mitigated the risks and potentially prevented the accident.
RS faces a complex risk profile due to a combination of outdated infrastructure, poor contractor management, inadequate security measures, and insufficient worker training. According to the HSE, developing a comprehensive risk profile is crucial for identifying and mitigating workplace hazards. Risk profiling models encourage organizations to consider a wide range of factors, including physical risks, human error, and external threats, when developing safety strategies. RS’s risk profile is characterized by four primary risks: outdated wiring and signalling systems, inadequate contractor management, vandalism and security breaches, and human factors such as insufficient training. The organization’s failure to address these risks in a proactive and coordinated manner created the conditions for the train collision. The decision to continue using outdated infrastructure, combined with the lack of contractor oversight, significantly increased the likelihood of an accident. The dilapidated signal box and the decision not to replace old wiring represent major physical risks that RS failed to address. Additionally, the frequent vandalism of the fencing and RS’s failure to implement better security measures increased the likelihood of public access to the tracks. Finally, the human error involved in the installation of the TrainDetect system, exacerbated by a lack of training and oversight, further contributed to the incident. RS’s risk profile reveals significant vulnerabilities across multiple areas, all of which contributed to the train crash. Addressing these risks through a comprehensive safety management plan is essential for preventing future accidents.
The RailStart (RS) case study illustrates the critical role of health and safety legislation in preventing accidents in high-risk industries such as railway management. RS and Contritum’s failure to comply with safety regulations, coupled with poor contractor selection and communication, led to a tragic train collision. The Health and Safety Executive’s (HSE) enforcement principles of proportionality and targeting highlight the importance of focusing on the most severe risks and ensuring that enforcement actions are appropriate to the breaches. By developing a more effective contractor management strategy, improving communication, and addressing the organization’s complex risk profile, RS can prevent similar incidents in the future. Ultimately, this case underscores the importance of robust health and safety management in ensuring worker and public safety in high-risk environments.
This Question Hasn’t Been Answered Yet! Do You Want an Accurate, Detailed, and Original Model Answer for This Question?
Copyright © 2012 - 2024 Apaxresearchers - All Rights Reserved.