A railway worker was struck and killed by a train travelling at 76mph while using an unsafe system of lookouts linked to two other deaths, a report found. Tyler Byrne, 30, became "distracted" while working on the track and was hit by the passenger train, investigators said today.
He may have not noticed his dangerous position as he showed a colleague how to inspect the line near Surbiton station, south west London, according to the findings released today. Investigators said trains were still running during the planned inspection using single lookouts to spot advancing trains - a system that should have been scrapped but was still being widely used when the accident happened, according to a new report by the Rail Accident Investigation Branch (RAIB).
The South Western Railway train driver, who had 18 years' experience, sounded a warning horn twice as the vehicle approached Mr Byrne, but no one could remember hearing it, the report added. Bosses at the depot where he worked were said to have known about two previous fatalities in Wales but still used the outdated system of unassisted lookouts to spot advancing trains, the RAIB said.
Mr Byrne was walking in a crossover line between two through lines near the station and was one of four track workers involved in inspections at the site at around 11.30am last February 9. The track worker was unaware of his "position relative to the train" and "lost awareness of his position", likely while teaching a junior colleague, the watchdog found.
The report published today stated: "He was unaware of his position probably because he had become distracted, either due to teaching an assistant or by undertaking an actual inspection. Once distracted, it is likely his deviation towards the line on which the train was travelling was exacerbated by the layout of the rails at the junction.
"The train driver sounded the train’s warning horn twice during the train’s approach but neither of the other two people working with the controller of site safety recalled hearing it."
Using lookouts was "the least safe type of system of work" that could be implemented when working on track, the RAIB said. But the ongoing use of the tactic had not been challenged in the years before the accident, investigators found.
Network Rail planned to get rid of unassisted lookouts but changes had not yet been implemented, the report added. It read: "The inspection was planned to be completed while trains were running with a safe system of work in place that used unassisted lookouts.
"This was the least safe type of system of work which could be implemented when working on track, but its ongoing use had not been challenged in the years before the accident. Network Rail had a programme in place to eliminate unassisted lookout working but this had not yet led to changes to the safe systems of work at the depot where the controller of site safety worked.
"Safety of people working on or near railway lines relies on the controller of site safety implementing and managing a safe system of work, however where they are also responsible for carrying out the work, they are at increased risk of becoming distracted. This can, and has, led to staff being struck by trains or being involved in near misses."
In light of the tragedy, the RAIB recommended track workers are given clear safe limits of where to operate when the line is still active. Better training throughout the rail industry on dangerous positions and to improve use of the train's horn as an urgent warning were also recommended by the RAIB.
Investigators also found Network Rail had not learnt from a previous similar double fatality in Margam, Wales, nearly a year earlier, when two workers were struck and killed by a train. Gareth Delbridge, 64, and Michael Lewis, 58, were hit by a Swansea to Paddington train in July 2019.
Network Rail's "long-term failure to improve the safety of people working on the railway" was an underlying factor in their deaths, a report published a year later found. Andrew Hall, chief inspector of Rail Accidents at the RAIB, said investigators found evidence managers at Mr Byrne's depot were aware of the Margam accident, but they "were convinced their circumstances were different".
He said following the latest report's publication: “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.”
Paramedics and firefighters rushed to the site of the accident at the time but Mr Byrne, from Aldershot, Hampshire, was pronounced dead at the scene.
John Halsall, Network Rail Southern region’s managing director, said in response to the findings: “My thoughts and those of everyone here at Network Rail are with Tyler’s family and friends. We know that nothing we say or do now will make up for the fact that he is no longer with us.
“We worked closely with the RAIB in their investigation and we support their recommendations. We recognised that we needed to accelerate our progress on safety, and we’ve worked to get to a place where we have almost no maintenance activity around open lines, including across the Southern region where we’ve made a 99 per cent reduction.
“There’s still more work to be done, however, and our track-worker safety programme is continuing to implement new technology and new ways of working to keep our people safe.”
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