Patrick Bolster

NetworkRail

Hl] 27 Nov 2019
UL

POPLAR CORONER'S

FAO: HM Senior Coroner The Quadrant MK

Poplar Coroner's Court COURT Elder Gate

127 Poplar High Street yield nes

London 9

E14 OAE 25th November 2019

Dear Madam

Ref: Inquest touching the deaths of Mr Benjamin Michael Haddon-Cave and

Mr Patrick Thomas Bolster (formerly Broughan)
Regulation 28: Prevention of Future Deaths Report 25 September 2019

Thank you for your Regulation 28 report sent to Mr Andrew Haines following the above inquest. We have
reviewed the points raised in your report and respond in detail below.

For ease of reference, we have included your questions in the body of our response and against each of your
questions, have set out: 1) the steps we are taking to address your concerns on a national, and where
appropriate, local level, and 2) how we will be ensuring compliance with each step, via the Network Rail
national recommendations and actions tracking system (“Network Rail CMO-Compliance Tracked Action”).

1. Coroner’s Q1: “The fence was marked down for annual inspections because there was no history
of problems in that area however the inspectors conducting the inspection on 27 October 2017
and 27 October 2018 (a different inspector on each occasion) did not consider the relevant part
of the fence because dense vegetation blocked their view from trackside.

Neither inspector attempted to view the fence from the other (public) side, which they could
easily have done.

This represents a failure of the two individuals and/or a failure of their training and/or both.
There are only 4 inspectors at Tottenham, so this represents half the inspections workforce.”

1.1 Network Rail Response- Q1:

1.1.1. National Safety Bulletin

A communication in the form of a National Safety Bulletin will be issued to all-Off Track teams, which is the
Network Rail maintenance teams that carry out boundary inspections. A National Safety Bulletin is the
fastest means by which Network Rail issues national learning of important or critical safety issues pending a
safety ‘Standard’ or process change.

In this instance, the proposed National Safety Bulletin will reference the key points from this tragic event.

Specifically, the Bulletin will state that where a tactile inspection is not possible, the inspector is to use
alternative means to view/inspect the fence, such as using:

Network Rail Infrastructure Limited Registered Office: Network Rail, One Evershoit Street, London, NW1 20N Registered in England and Wales No. 2904587 www.networkrail.co.uk

° The other (Public/3rd Party) side

° Alternative vantage points
° Removal of vegetation (where appropriate)*
. Use of technology (e.g. drones)

* where the vegetation acts as part of the deterrent boundary measure, this is not removed to facilitate an
inspection. A non-tactile form is acceptable.

Network Rail CMO-Compliance Tracked Action 1: National Safety Bulletin to be issued to all off track
section teams that carry out boundary inspections - Due by 30th November 2019

1.1.2. Competency Training Module

Network Rail was previously aware of the need to improve the competency of rail boundary inspections and
had provided an improved safety Standard and competency training module. This is a 2-day specific
mandatory training course for all new and existing inspectors. In light of the tragic fatalities at Hackney
Wick, we have identified that the new competency module should be further enhanced by explicitly
stipulating what to do where non-tactile inspections cannot be carried out from the Network Rail trackside.

This enhancement will be included in the training course from April 2020 following the issue of the revised
Standard.

Network Rail CMO-Compliance Tracked Action 2: Principal Lineside Engineer to update competency
module to explicitly stipulate what to do where non-tactile inspections occur — Due by 31st March 2020

1.1.3. New Boundary Fencing Inspection Standard

It should be noted that since the tragic fatalities, the revised Standard for Boundary Fencing Inspection
(NR/L2/OTK/5100 Module 01) has now come into force (1st April 2019). Importantly, this Standard dictates
the Network Rail system to be followed, which includes a new electronic form F3212 to replace the previous
paper TEF 3212 form.

The revised Standard requires all inspectors to input the inspection data via the electronic MyWork App
which includes the F3212 form. In the event that a tactile inspection cannot be undertaken, the Standard
requires the inspector to use the F3212 form to record that fact. The F3212 form includes a new section
that the inspector must complete that records how the incomplete inspection can be undertaken as a tactile
inspection.

Once an incomplete inspection has been uploaded to the data recording system (“Field Data Manager”), this
will flag to the Track Maintenance Engineer that a non-tactile inspection has occurred. The Track
Maintenance Engineer is then required to review the system and review the details of the F3212 form.
Depending on the contents and photographs supplied, the Track Maintenance Engineer can either challenge
the inspection approach or accept that a non-tactile is appropriate and pass the report on to the Route Asset
Manager for approval.

The Route Asset Manager follows the same process as the Track Maintenance Engineer by either
challenging or approving the non-tactile inspection. The Track Maintenance Engineer and Route Asset
Manager are required to only approve a non-tactile inspection if there is no reasonable way to undertake the
inspection or the reason preventing the inspection acts as the deterrent to access.

1.1.4 Future enhancement to the Boundary Fencing Inspection Standard

We have identified an opportunity to be more detailed in the Standard for non-tactile inspections. The
Standard ‘NR/L2/OTK/5100’ will be amended in the next review cycle (March 2020 to make it clear that in
the event a tactile inspection is not possible, further work may be required to complete the tactile inspection.

Network Rail CMO-Compliance Tracked Action 3: The Standard NR/L2/OTK/5100 Module 1 will be
amended to be more explicit regarding work arising to enable future tactile inspections - Due by 31st
March 2020

1.1.5. Tottenham Delivery Unit. improvements

In terms of the Tottenham Delivery Unit, Inspectors that were involved in the inspections in 2017 and 2018
were both deemed competent, however it is worth noting that both inspectors along with the remaining
team have been through a new competency module ‘TR51- Boundary Measures Inspection’ during 2019.

In addition, all Inspectors in Tottenham Delivery Unit have been re-briefed by the Section Manager on how
they are to approach non-tactile inspections which include arranging for vegetation, where necessary and
appropriate, to be cleared and/or the boundary to be accessed by alternative means (e.g. via the non-
Network Rail (public) side) to undertake the inspection.

As a further measure, the Route Lineside Senior Asset Engineer within the Route where Tottenham Delivery
Unit are located is undertaking a set of onsite reviews with all Route inspectors using recently created non-
tactile inspection reports. This is to review the reports and the process followed prior to submission of the
reports. All inspectors in the Route will have been reviewed by 31st December 2019. We can confirm the
inspectors involved with the fencing inspections linked to the tragic deaths have already been reviewed by
the Route Lineside Senior Asset Engineer.

Network Rail CMO-Compliance Tracked Action 4: Anglia Route Lineside Senior Asset Engineer to
undertake a set of onsite reviews with all inspectors where non-tactile reports have been submitted —
Due by 31st December 2019

2. Coroner’s Q2: “Both Inspectors inputted their inspections onto a computer system but neither
submitted a paper form as they were meant so to do.

This represents a failure of the two individuals, and/or a failure of their training and/or both.
In any event, such a system of dual submissions was inherently flawed”.

2.1 Network Rail Response-Q2:

2.1.1. The ‘Boundary Measures Network Rail Standard’ (NR/L2/TRK/5100) in force at the time of the 2017
and 2018 inspections and in force at the time of Benjamin Michael Haddon-Cave and Patrick Thomas
Bolster’s tragic deaths, made it permissible to use either paper or electronic forms. Network Rail was aware
of the flaws in this Standard prior to the inquest and had revised the national Standard to
(NR/L2/OTK/5100) which came into force in April 2019. This Standard specifies that only electronic records
are to be used from the 31st August 2019. In terms of the system we now require a single electronic system
to be used.

2.1.2. Additional Support Training

In addition to the 2-day Boundary Inspection Competency module, additional support training has been
rolled out on a section manager requested basis between April and October 2019. This support training
covers the use of the Electronic system and how to record the various inspection data via the ‘MyWork App’
and the related electronic forms. Nationally we have trained the 250 plus delivery unit personnel that
requested the support training. This will be rolled out as requested by the business areas.

2.1.3, National Special Inspection Notice

Due to the risk of other inspectors using mixed systems for recording inspections, a National Special
Inspection Notice (SIN) will be issued by the Standard Owner for Boundary Inspections within the National
Safety, Technical and Engineering (STE) Department. A SIN is the methodology used by Network Rail to
instruct a specific activity to be carried out and which requires confirmation that it has been completed.
Every SIN is given a specific timeframe for compliance and is tracked and reported nationally. This is often
used for safety related actions required to the infrastructure.

This SIN will require all areas of the business to confirm they are following the Standard regarding the use of
electronic forms, that all forms have been reviewed and correctly signed off and that repeat non tactile
locations have been appropriately risk assessed.

Network Rail CMO-Compliance Tracked Action 5: National Special Inspection Notice (SIN) to be issued
by the Principal Engineer [Lineside] re population of electronic form F3212 and risk assessments. — Due
by 31st March 2020.

2.1.4 Local Route changes

The Anglia Route are using the electronic system for all inspections following the revised Standard coming
into force. This includes recording the non-tactile inspections via the electronic system. The Route will be
carrying out a compliance check in November 2019 as part of our assurance activity following the inquest
and new Standard changes, to confirm that all inspectors are using the electronic system and the forms are
recorded electronically only.

3. Coroner’s Q3: “As a consequence of no paper forms being submitted, the track engineer did not
see the evidence of the failure to inspect the fence, and was so not in a position to challenge
this.

This represents a system failure”.

3.1 Network Rail Response-Q3:

3.1.1 We are currently investigating to what extent a similar dual paper and electronic approach similar

to Tottenham DU is used nationally. In the event that it is a national issue, the SIN to be issued will address

this dual system and will require any backlog of forms that have not been reviewed to be addressed by the

compliance date to be set within the SIN.

Network Rail CMO-Compliance Tracked Action 5

3.1.2 Ona local level, the failure has been addressed by taking the following steps:

e All Anglia Track Maintenance Engineers have been briefed to utilise and maintain the
Electronic system and not maintain paper records. This action was taken following the inquest
and Network Rail’s investigation into these tragic deaths.

e The Engineers will be receiving a new report showing what is in the system for processing and
the report will flag two consecutive non-tactile inspections, plus any forms not processed to
completion within 180 days. This will allow the Engineers to check that suitable challenge has
occurred for those locations or actions to close are in progress.

4. Coroner's Q4: “As a consequence of no paper forms being submitted, the internal auditor did
not see the evidence of the failure to inspect the fence or the evidence of the failure to
challenge, and so were not in a position to highlight this.

This represents'a system failure”.
41 NR Response Q4:
4.1.1 Internal auditing

The previous Standard in force allowed the use of either paper or electronic systems. The lesson from these
tragic deaths will be shared with our national audit teams so they can share the lesson. The audit protocol
has been changed, since the audit referenced above, to reflect the new Standard and all auditors will be
checking to the new Standard including checking of the electronic records.

Following the inquest and this report, we are planning to amend the Audit protocol with a guidance note
added to review example F3212 from the range of inspectors. This will be implemented from June 2020 in
time to the next.round of National team audits on the Maintenance sections of the business.

Network Rail CMO-Compliance Tracked Action 6: Principal Lineside Engineer to change Audit protocol
and a guidance note to be added to review examples from all inspectors —- Due by 30th May 2020.

5. Coroner’s Q5: “Network Rail identified the gap.in the fence within weeks of the deaths but
despite what was described as a full internal investigation, the system failures I have described
were only discovered after the inquest had resumed on 30 August 2019. Their original
investigation was inadequate.

Network Rail had been operating for the previous five and a half months on the basis that this
was a localized problem. Even after an adjournment to facilitate further investigations, a

senior Network Rail representative gave evidence to that effect on 13th September 2019.

Yet the reality is that Network Rail does not know if it has a national system failure of fencing
inspections”.

5.1 Network Rail Response Q5:

Network Rail is committed to this action and has reviewed the national data, to date we have sampled 20%
of the Off Track Sections nationally and the process is ongoing. A special topic audit on compliance with the

new boundary inspection Standard re non-tactile forms will be undertaken by the Network Rail National
Audit Team within the next 3 months to identify whether we have a national failure and to what extent.

Network Rail CMO-Compliance Tracked Action 7: Principal Lineside Engineer to commission a National
Special Topic Audit by Network Rail National Audit team on compliance with the new boundary
inspection Standard re non tactile forms - Due by 31st January 2020.

This report has been submitted to the National Recommendations and Review Committee (NRRP) on 3rd
November and the actions identified have been logged within our central recommendations tracking system
(CMO-Compliance) and will be tracked via this system to conclusion. Reporting of outstanding actions are
flagged to the National and Regional Executive teams for awareness and follow up.

Network Rail is committed to learning from tragic events such as this case and we are always seeking to
improve our safety record. We have been saddened by the circumstances in which Benjamin Michael
Haddon-Cave and Patrick Thomas Bolster lost their lives and will be taking these actions forward as a
Priority.

Yours faithfully,

Group Safety, Technical & Engineering Director
for and on behalf of Network Rail