Shortly after 6am on 21st October 2021, a passenger train travelling at 123 mph struck a hand trolley that had been left on the track near Challow in Oxfordshire.
No one was hurt and the train stayed on the tracks but the trolley was smashed to pieces. Debris caused damage to equipment under the train and there was some minor damage to the track.
A maintenance team had carried out overnight work and no one noticed the hand trolley left behind on the track, exposing weaknesses in the ‘line clear verification process’, RAIB said.
A probable contributing factor was that hand trolleys were being routinely used at night without displaying any red lights and that no assurance activities were taking place within work sites to monitor compliance to this requirement.
RAIB has made five recommendations to Network Rail. The first is to establish how the existing line clear verification process can be improved. The second is to consider what technology could be used by its staff to support the process. The third recommendation is to propose an amendment to the Rule Book so that hand trolleys are required to display an illuminated red light in both directions at all times when on the track. The fourth is for Network Rail to have processes in place to ensure that any hand trolley placed on its track has illuminated red lights displayed in both directions. The fifth recommendation is to review the effectiveness of its safety assurance activities which check that hand trolleys are being used correctly and safely.
RAIB also identified three learning points. The first reminds maintenance staff about the importance of complying with all rules and standards concerning how trolleys and rail skates should be used on Network Rail’s infrastructure. The second highlights the importance of clear communication between the staff at a train involved in an accident and those based in control rooms to establish what damage has been sustained by a train, so that the appropriate controls can be put in place before the train is permitted to move. The third is that staff involved in planning maintenance work produce documents that are accurate, appropriate and specific for the task that is being carried out, and involve those responsible for the work in the planning of it.
Chief inspector of rail accidents Andrew Hall said: “Systems and processes designed to detect any equipment left on the track before lines re-open after maintenance work, should not be reliant solely on human performance in the middle of a dark night. There are technological solutions which can assist with addressing this issue, and this accident is an example of an opportunity missed.
“Our investigation found that the railway had identified the risk of equipment, such as hand trolleys, being left on the line and that it could mitigate this risk by improving the line clear verification process. However, it had not yet implemented the changes required when this accident occurred. This meant that the process remained vulnerable to human error. In this case, this vulnerability was made worse because relevant procedures were not followed correctly. Technology has an important role to play in improving the safety of the railway and it is important that the development of solutions to better support staff are prioritised.
“It is also a concern that hand trolleys were routinely being used on the track at night without displaying red lights. But it is of equal concern that no activity to monitor this requirement was being undertaken. Once again, assurance activities intended to check that rules are being followed and that processes are being implemented correctly were not effective.”
Got a story? Email news@theconstructionindex.co.uk
.gif)
