Network Rail fined £3.75 million for South Wales track worker deaths

Network Rail has been fined £3.75 million and ordered to pay costs of £175,000 over the deaths of two railway workers at Margam in South Wales in 2019, after pleading guilty to failing to ensure the safety and welfare of its workers.

In a report, Network Rail admitted that it had failed the workers leading up to the accident with “systemic and serious failures” highlighted by David Travers KC, representing the families of the two victims.

Gareth Delbridge, 64, and Michael Lewis, 58, were hit by a Swansea to Paddington train on the Up line at 0952 on July 3, 2019. A third worker who was working with both Delbridge and Lewis has been left with severe trauma. All three workers had been working on the line in a red zone setting (meaning that the line is open to train movements) as part of a group of six.

The court heard however that the workers had believed there was “no need to wait” to carry out the maintenance on the track in the morning despite there being a line blockage arranged from 12.30 onwards in order for the work to be carried out without train movements.

The group had intended to use a “lookout” system, which is common whilst conducting red zone working. This system requires both a distant lookout and a touch lookout nearer to the workers, however no distant lookout had been appointed or used, and the touch lookout was looking for both Up and Down line trains whilst also working on site. Network Rail’s safety protocol requires the lookout not to conduct any work.

The court heard that Network Rail had attempted to introduce significant and complex changes to the safety protocols called Section 19 however these changes had not been properly implemented and the briefings for the changes had been “insufficient and under-resourced” according to Travers.

This had led to confusion and inadequate training for workers at the Port Talbot depot where the workers including Delbridge and Lewis had been stationed. Alongside a failure in safety training, the court also learned that the planned works had not involved the Person in Charge (PIC) who would ultimately oversee the delivery of the work and the person in control of site safety had been appointed at the site in contravention of the safety protocols in place.

None of team present at the day of the incident had challenged any unsafe working either.

Systemic failures by Network Rail in not recognising the dangers and issues was blamed by the Judge, Recorder Jowett as one of the main causes of the deaths.

Speaking in court, Recorder Jowett said Standard 19 was “substantially based on a number of unsuccessful initiatives since 2014”, following previous deaths in 2011 and 2012.

“I find that Network Rail therefore must have had a good understanding of why these initiatives failed.”

He added, “However, I also find that it didn’t learn from these experiences because the design and rollout of Standard 19 repeated a number of mistakes and introduced further mistakes.”

This included issues with line blockages. The court learned that workarounds had developed in both planning and maximising the amount of people available to work on the track at the expense of adequate lookout protection. It was argued by Travers that this was the case that whilst the stretch of line between Moors and East Junction was a two-line railway, blocking the Down line and then the Up line was seen as logical, it meant that signallers were put under an increased amount of pressure.

This led ultimately to limited access opportunities to complete planned maintenance.

The court also heard that a pressure to keep the line open and therefore achieve the route’s KPI’s as well as an “habitual non-compliance” that had been left unchallenged by senior management had also contributed to the accident.  

Travers said at the hearing: “Network Rail fell short of the standards it had set, ignored people on the ground which had said that the safety protocols in place would not work, and they allowed issues to subsist for a lengthy period of time.”

“Network Rail did not commit the will or the resources to tackle it.”

A previous investigation found similar issues, described at the time by the Rail Accident Investigation Branch (RAIB) as a “catalogue of errors”, leading up to the incident and had made 11 recommendations including improving safe work planning processes, developing safety behaviours among staff, and conducting research into sounding train horns automatically.

Outside court, Nick Millington, route director for Wales & the Borders, said: “We know that the tragic deaths of our colleagues, Gareth Delbridge and Michael 'Spike' Lewis, should never have happened on our railway and that has been reflected by today's judgment.

"Over the last five years I have met regularly with Gareth and Spike's families and our thoughts remain with them, and all those friends and colleagues who have been impacted by their deaths.

"Since this tragedy, we have continued to transform the safety of our workforce through the development of new technology and planning tools, which have almost entirely eliminated the need to work on the railway when trains are running. “Today’s judgment reinforces why safety must always be our first consideration, and we will continue to do all we can to make our railways the safest they can be.”

His majesty’s Chief Inspector of the Railways Richard Hines added: “Our thoughts continue to be with the family, friends and colleagues of Michael Lewis and Gareth Delbridge.  I am deeply sorry for their loss.”

Mark Phillips, CEO, The Rail Safety and Standards Board (RSSB) commented: “This tragic accident was a catalyst to completely rethink track worker safety.

“Our research and analysis helped Network Rail make significant safety improvements, with our statistics showing the number of track worker near misses with trains reducing from 60 per year in 2018/19 to 22 in 2023/4.

“This is still a priority issue for RSSB, and we are developing new solutions to protect track workers, including a predictive tool to reduce the risk of runaway machinery, changing standards to stop the highest risk activities and researching how geofencing can improve safety at work sites, keeping staff within safe areas.”