The Rail Accident Investigation Branch has released a report regarding the death of a worker who was hit by a train near Surbiton station last year.

At around 11.35am on February 9, 2021, a train travelling at 76 mph hit a track worker who was walking in a crossover line between two through tracks.

The worker’s role was the controller of site safety, and he was one of the people who were carrying out track inspections there while trains were running in the area.

The Rail Accident Investigation Branch said that it was likely that the man “who was carrying out inspections and was also responsible for the group’s safe system of work had become distracted and lost awareness of his position relative to the line the train approached on”.

Unassisted lookouts were also used to try and prevent accidents.

The report explained that this was “the least safe of system of work when working on track,” but it had been used for years and was unchallenged before the accident.

Office of Rail and Road have recorded five workforce fatalities in 2020-21 in the UK, compared with three in 2019-20.

It is said that the train driver sounded the train’s warning horn twice during the train’s approach but neither of the other two people working recalled hearing it.

Network Rail had plans to scrap unassisted lookout working but this had not yet led to changes at Surbiton Station.

The safety of people working on the railway lines relies on the controller of site safety managing a safe system of work.

However, the controller of site safety is also responsible for carrying out the work meaning that they have an increased risk of becoming distracted.

The learning points that the report has put forward include train drivers need to sound an urgent warning horn where there is doubt whether workers have moved clear of the line.

Track workers need to look to confirm on which line a train is travelling when they hear a warning horn.

The people who create the patrol layouts need to have a strong understanding of the distance from that position and the active tracks.

Workers who are involved in preparing safe work systems need to consult the patrol diagrams to check for inconsistencies.

Track workers should also have quick access to emergency contact details.

Andrew Hall, Chief Inspector of Rail Accidents said: “As RAIB publishes its report on the tragic death of a track worker at Surbiton last year, our thoughts are with his family and friends.

“After a period of almost five years with no fatalities involving moving trains, track maintenance staff have died in accidents each year from 2018 to 2021.

“In 2019, two track workers were killed near Margam in south Wales, and our investigation found unsafe working practices that had not been detected by Network Rail’s management assurance arrangements.

“At Surbiton, the accident happened probably because a patroller, who was carrying out inspections and was also responsible for the group’s safe system of work, had become distracted and lost awareness of his position relative to the line the train approached on.

“The patrol was being undertaken with protection provided by unassisted lookouts.

“Although this was the usual practice for these inspections working with unassisted lookouts is the least safe type of system allowed for when working on track and this had not been challenged in the years leading up to the accident.

“We found evidence that people at the depot involved were aware of the Margam accident, but they were convinced that their circumstances were different and that the earlier lessons did not apply to them.

“Consequently, managers at the depot did not learn from the experience of Margam and continued to allow much work to be carried out under unassisted lookout protection.

“While Network Rail has made great strides in reducing the amount of track maintenance work undertaken when trains are running, it remains the case that many of the recommendations that we made in the Margam report are relevant to the accident at Surbiton.

“I urge everyone involved with track maintenance to look closely at what happened here, and learn from it, so that deaths at work on the line really do become a thing of the past.”