A train came within 75 seconds of potentially crashing into a track maintenance machine, an investigation has found.
The near-miss at Balham station, south-west London, occurred due to poor communication by Network Rail workers, the Rail Accident Investigation Branch (RAIB) said.
Shortly after 7pm on April 20 last year, a tamping machine was mistakenly driven onto a line which had not been closed to trains during the maintenance work.
It crossed a junction through which a Southern train from London Victoria to East Grinstead had passed just 75 seconds earlier.
The investigation found that the mistake happened because the person responsible for train movements in the area where the work was taking place provided “incomplete information” about the location of the tamping machine.
It was noted that the two people who shared this role during the weekend when the work was taking place spent a “significant proportion” of time working from their homes, amid a lack of “clear guidance” on where they should be based.
Analysis of background noise during telephone conversations suggests their home environments “may have resulted in distraction”, according to the report.
Safety critical communications were “poor throughout” and resulted in “no party having a clear understanding” of where the tamping machine should be, the RAIB stated.
Investigators noted that a collision between two freight trains at Logan, East Ayrshire, in August 2015 also arose from inadequate communication.
Network Rail’s management of the role of overseeing train movements at engineering work sites was described as “ineffective”.
‘Not the first time’
Chief inspector of rail accidents Simon French said several people involved in the Balham incident failed to challenge information or instructions which were confusing and inconsistent.
“This is not the first time this has led to trouble, and the consequences can be disastrous,” he warned.
“Our investigation found a culture of poor communications among staff involved with engineering work. People were embarrassed to use the proper protocols when passing messages to colleagues.
“The aviation industry confronted this problem head-on many years ago, and now any pilot or air traffic controller who does not use the correct form of words and phrases would instantly stand out as less than competent.
“We are challenging the railway industry to come into line with aviation, and embed the same standards among its people.”
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