Safety inspectors are demanding Network Rail implement “real change” after the death of two track workers in south Wales, saying the underlying causes had been “repeatedly highlighted” by 44 investigations since 2006. The Rail Accident Investigation Branch’s final report found that the workers were struck by a train after starting an “unnecessary maintenance activity” on the south Wales mainline hours before it was due to close. They were unaware of the train’s approach, despite its emergency braking and sounding the horn, because they were wearing ear defenders and no lookouts were posted. Gareth Delbridge, 64, and Michael “Spike” Lewis, 58, died after being hit by the Swansea to London train near Margam on 3 July 2019. A third man with them narrowly avoided being struck. Investigators found that the working system proposed by the controller of site safety was not followed, and the informal practices became “progressively less safe … and created conditions that made an accident much more likely”. The RAIB said Network Rail had failed over many years to properly address the protection of track workers. It had “focused on technological solutions and new planning processes”, but not “adequately taken account of the variety of human and organisational factors” – and while aware of the need for change, had not implemented plans in time. The chief inspector of rail accidents, Simon French, said the deaths had “had a profound effect on all of us” in the railway industry. He said: “The areas that need to be addressed to improve the safety of track workers have been repeatedly highlighted by 44 investigations carried out by RAIB over the last 14 years. “It is frustrating that the railway has been unable to carry people with it in its attempts to bring about real change. I remain hopeful that the rail industry will find a way to address these thorny and persistent issues. There is now a real sense that things must change.” Network Rail’s safety director, Martin Frobisher, said: “We owe it to Gareth and Spike to do everything in our power to prevent another tragedy on our railway. We have already taken action to improve safety for rail workers, making changes to how work is planned and carried out, and improving safety leadership and culture within the organisation.” A separate investigation is continuing by the regulator, the Office of Rail and Road (ORR), which could lead to prosecution and fines for Network Rail. The regulator had already demanded improvements following earlier near misses. ORR’s chief inspector, Ian Prosser, said: “Track worker safety is paramount and in the 18 months prior to the incident at Margam we undertook additional inspections following our growing concerns that Network Rail was not doing enough to control risks to track workers.” However, he acknowledged Network Rail had formed “a significant taskforce” to improve safety.