Basis for Recommendation
This accident illustrated blatant disregard for the IÉ Rule Book, and the events which occurred afterwards, in terms of attempting to conceal the severity of the accident, indicate that the level of supervision, at the time of the accident, was not appropriate. This is also evident through the accident at Clonygowan, where there was also deliberate rule breaking by IÉ-IM staff members; and, the anecdotal instances of noncompliance with the safety rules and regulations within work sites. The RAIU consider that improvements must be made for the short, medium and long term to address supervision. The Safety Tours, as set out in CCE-SMS-008, were ineffective at capturing rule breaks prior to possessions being granted, such as work parties accessing the railway before the possession being granted and equipment left near the railway line overnight. As a result, the RAIU make the following recommendation:
IÉ-IM should review the current system of supervising and monitoring T3 Possessions, in terms of possession arrangements (e.g. Authority Number) and safety documentation (e.g. method statements); this review should identify improvements in terms of managing T3 Possessions. At a minimum, IÉ-IM should:
- Expedite an increase in the supervision and monitoring of T3 Possessions by Engineering Department staff through updating CCE-SMS-001, specifically increasing monitoring prior to possessions being granted (while the IÉ-IM review and updating of supervision and monitoring of T3 Possessions is being undertaken);
- Revise the current process of monitoring possessions through Safety Tours, CCE-SMS-008, to ensure the requirements of all guidelines are recorded in the Safety Tour Form;
- Once the Safety Tours, CCE-SMS-008, documentation has been reviewed and updated, verify that the Safety Tours are being carried out correctly, and in full accordance with the guidelines, through an auditing process.