Formal Inquiries

Harlow Mill report and recommendations

Railway Safety has issued its formal inquiry report into the circumstances that led to injuries being sustained by a track worker from the overhead electrified line whilst stood on top of a wagon at Harlow Mill on 5 May 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

GrantRail had been contracted by Railtrack PLC to undertake renewals of sleepers between Harlow Mill and Bishops Stortford on weekends over a period of weeks. For this work to be carried out a T(iii) possession had been granted and the worksite was set up using marker boards at it's extremities with an isolation of the electrical supply over the length of the possession.

The possession and worksite was later extended towards Harlow Mill station and the marker boards were moved, although there was no update of the method statement to reflect this.

On Sunday 5 May 2002, wagons loaded with spoil from the worksite had been moved up to the marker boards at Harlow Mill station whereupon the train preparer asked for the uneven load be redistributed in three of the wagons.

Two track workers were sent from the relaying site to the wagons to flatten the loads. This work was conducted under live overhead line equipment (OLE) outside of the isolated and earthed section.

At approximately 0946hrs one of the track workers, whilst standing on top of the wagon, came into contact with the live overhead line equipment and as a result, suffered severe electrical burns.

Conclusions

The formal inquiry panel concluded that the immediate cause of this accident was the track worker climbing on top of the wagon to flatten the load in response to instructions he had received.

The panel also concluded that there were a number of underlying causes of the accident, summarised as follows:

• A failure to understand and implement a permit to work system as part of the safe system of work, in so doing failing to comply with Section Z(i) of the Rule Book.
• Staff working with only verbal assurances given by persons who lacked information about the safety of the activity/environment.
• Insufficient and unsuitable method statement for working in conditions where the OLE is live.
• A failure in the change management process for the method statement, eg changes to the hazards present were not risk assessed.
• Staff at the worksite lacked an understanding of their roles and responsibilities.
• Staff lack of basic knowledge of Rule Book sections despite certification.

Recommendations

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

• Update of the Rule Book and Railtrack's company standards to use the same wording to avoid ambiguity over arrangements for working with OLE and the use of a permit to work system.
• The use of signage on electrical structures to identify the limits of isolation of electrical equipment.
• Update the Rule Book and the Personal Track Safety Handbook to include information about risks associated with standing in open wagons under live OLE.
• The principles of using OLE permit to work systems to be included in the Personal Track Safety certification training.
• Method statements to include risks from electrified lines, changes to them are properly managed to incorporate any change in plans and that revised information is advised to all those concerned.
• Actions to ensure that site supervisors, Controllers of Site Safety (COSS) and Engineering Supervisors (ES) are briefed about the management of the OLE Permit to Work system.
• Actions to ensure that each ES and COSS has a clear understanding of their roles and responsibilities in managing site activities.

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.