Summary
At around 1142 on 29 April 2025, a passenger train was involved in a near miss with a team of three track workers walking through Bookham Tunnel, on the approach to Bookham station in Surrey. The train was travelling at 33 mph (53 km/h) as it passed the team. The track workers either moved to refuges inside the tunnel or stood against the tunnel wall as the train passed them.
RAIB’s investigation found that the track workers were walking in a different location to that which had been blocked to trains and that neither the track workers, nor the signaller who had granted the line blockage, had realised this. This happened because the safe work pack, which formally detailed the safety arrangements for the task, incorrectly contained line blockage arrangements for the nearby Mickleham Tunnel, and not the tunnel around which the team was working. The error in the safe work pack had been introduced during the planning stage for the work and went unnoticed, despite the pack being checked multiple times during various stages of the safe work process.
RAIB identified two underlying factors. The first was that Network Rail’s lack of a specific process for managing the transfer of information between its asset management systems and the system it uses for producing safe work packs allowed the introduction of the error into the safe work pack. The second was that steps in Network Rail’s process for producing safe work packs were either not routinely carried out or were not carried out effectively.
Recommendations
As a result of its investigation, RAIB has made three recommendations to Network Rail. The first recommendation aims to reduce the risk of errors being introduced when using information from multiple systems to produce a safe work pack. The second aims for Network Rail to improve the implementation of its process covering work taking place on or near operational railway lines. The third recommends Network Rail improves its assurance activities by better using the information provided by its safe system of work planning software.
RAIB has also identified two learning points. The first of these reminds track workers and signallers undertaking safety-critical communications of the importance of clarity, effective listening, and reaching a clear and unambiguous understanding of what has been agreed. The second is that staff who plan work on or near the line, and those who then deliver that work, are reminded of the importance of coming to a clear understanding about how all planned activities, including the walking and working elements, will be undertaken.
Andrew Hall, Chief Inspector of Rail Accidents said
The move away from unassisted lookout protection on the railway has made track work statistically safer, and that is welcome. However, our investigation into this near miss illustrates how safety is now heavily dependent on every worker having an accurate understanding of which lines are blocked, the timing of the block and where the safe working boundaries lie.
Bookham Tunnel is one of a number of near misses that serve as a warning. Safety theory and bitter experience both tell us that a pattern of near misses will eventually end in tragedy, and that is what happened in Hertfordshire in March this year, where a track worker was struck and sadly lost their life. I know that work continues to try and reduce this risk further. Recent events show how urgent and important such work is.
Notes to editors
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The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.
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RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.
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