Formal Inquiries

East Croydon report and recommendations

Railway Safety has issued its formal inquiry report into the workforce fatality at East Croydon on 8 September 2002. The formal inquiry was convened under independent chairmanship and included representatives on the panel from the involved parties. As with all such inquiries the panel's task was to establish the immediate and underlying causes of the accident and make recommendations to prevent or reduce the risk of recurrence.

Sequence of events

On 8 September 2002 a four-man team of workers, employed by infrastructure maintenance contractor AMEC, was working in the East Croydon area as part of a programme to fit protective tubing around cabling on DC electrified lines.

In this instance the work was being carried out with the lines open to traffic, and with the conductor rails live. The team had been working for about an hour when the COSS came into contact with the conductor rail and the running rail on the Up Slow line at 0955hrs. Colleagues dragged the COSS clear of the line and attempted to administer first aid. The emergency services were called but paramedics were unable to revive him and he was pronounced dead at the site of the accident.

Conclusions

The formal inquiry panel concluded that the immediate cause of this fatality was the COSS coming into contact with the live conductor rail. The panel was unable to ascertain exactly what caused the COSS to fall and come into contact with the rail. However, they concluded that the work being undertaken with the conductor rails live and with lines open to traffic was an underlying cause of the accident.

Recommendations

The report makes recommendations for improvements in a number of key areas and these are summarised as follows:

• This type of activity to be undertaken with lines closed to traffic and conductor rails isolated.
• A review of the standards, processes and equipment used when the conductor rail cannot be isolated for this type of work.
• The production of specific method statements for this type of work and their use to brief work teams.
• A review of emergency contact procedures instructions and arrangements.
• A review of the arrangements for table-top emergency exercises.
• Synchronisation of voice recorder clocks.

Railway Safety has issued a full copy of the report to each member of the Railway Group and the other organisations involved in the accident. All recipients of the report need to review the findings and recommendations and take actions where appropriate to address identified deficiencies within their own systems. Railway Safety will track the industry's response to this report.