Planning and Communication Failures Behind Surrey Rail Near-Miss, Investigation Finds

A series of planning errors, incorrect documentation and communication failures nearly resulted in a serious accident on the railway in Surrey, according to a newly published investigation by the Rail Accident Investigation Branch (RAIB).

The report examines a near-miss involving three Network Rail maintenance workers who came within seconds of being struck by a South Western Railway passenger train inside Bookham Tunnel on 29 April 2025.

At approximately 10:54am, a train travelling from London Waterloo to Guildford was approaching Bookham station and slowing as it entered the tunnel. Despite reducing speed, the train was still travelling at around 33mph when the driver spotted the workers ahead on the track.

Recognising the danger, the driver immediately sounded the horn. The warning gave the workers only moments to react, forcing them to seek refuge in emergency recesses built into the tunnel walls or press themselves against the structure as the train passed.

Investigators found that the maintenance team had no awareness they were exposed to live traffic. They believed a formal line blockage had been arranged and that trains had been prevented from entering the section where they were working.

However, the protection in place covered a completely different location.

According to the RAIB, the signaller responsible for authorising the blockage granted protection for the Down Portsmouth line at nearby Mickleham Tunnel rather than the Down Bookham line where the work was taking place. As a result, the workers were operating in an area that remained open to train movements.

The investigation concluded that the underlying cause of the incident could be traced back to deficiencies in the planning process. A signalling and telecommunications planner inadvertently confused the two tunnel locations and combined separate jobs into a single Safe Work Pack (SWP).

Safe Work Packs are critical documents used to set out the safety arrangements, work locations and protection measures required before any activity takes place on or near the railway.

In this case, the documentation contained protection arrangements for Mickleham Tunnel but failed to include Bookham Tunnel. Because of this error, a number of required verification checks were either missed or completed inadequately. The report noted that the work pack was later approved remotely by a section supervisor, who did not identify the discrepancy between the planned worksite and the protection arrangements.

Further problems emerged on the day of the incident when the Person-In-Charge (PIC) requested the line blockage from the signaller. Although the PIC verbally stated that the team was working at Bookham Tunnel, they simultaneously read out track reference information associated with Mickleham Tunnel from the flawed paperwork.

Faced with conflicting information and managing other operational demands, the signaller failed to recognise the inconsistency and authorised the blockage based on the incorrect reference details.

Beyond the immediate mistakes made by individuals, the RAIB highlighted broader

organisational shortcomings within Network Rail’s planning systems. Investigators criticised the lack of automated integration between the company’s asset management database, Ellipse, and its planning platform, RailHub. The absence of automatic data transfers increased the risk of information errors being introduced into safety-critical documentation.

The report also found that local management processes designed to identify and correct such mistakes were not consistently applied, allowing inaccuracies to pass through multiple stages of review.

In response to its findings, the RAIB has issued three recommendations aimed at strengthening railway safety. These include introducing more robust automated data handling processes, improving compliance with track safety procedures, and enhancing digital audit and monitoring functions within RailHub.

Chief Inspector of Rail Accidents Andrew Hall said that while the rail industry’s move away from traditional lookout-based protection has improved overall safety, it has also increased reliance on workers having a precise understanding of line blockages and worksite boundaries.

He warned that incidents such as the one at Bookham Tunnel demonstrate the risks that arise when critical information is incorrect or misunderstood.

Hall noted that the Surrey near-miss forms part of a wider pattern of safety events across the network. He referenced the fatal incident in Hertfordshire earlier this year, in which a track worker lost their life after being struck by a train, describing it as a stark reminder of the consequences that can follow repeated warning signs.

The RAIB concluded that while efforts are underway across the industry to reduce track worker risk, recent events underline the urgency of implementing further improvements before another near-miss develops into a tragedy.