Formal Inquiries

Chelford report and recommendations

The Rail Safety and Standards Board has issued its formal inquiry report into the circumstances that led to the fatality of a contractor whilst working at Chelford on 23 February 2003.

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

Materials were being unloaded from an engineering train occupying the Down main line of a four line section of track south of Chelford Station. Five road rail vehicles, each with an operator, crane controller and labourer moved the materials from the wagons to the cess. At approximately 1700hrs the train was moved 400 metres towards Chelford Station. Three road rail vehicles were positioned on the Down side and two on the Up side of the train. A further movement of the train towards Chelford Station was made at 1730hrs. At this time one of the road rail vehicles on the Down side of the train was unloading materials from the second wagon. The labourer who was on the wagon attaching the straps of a bag of aggregate to the jib of the road rail vehicles became trapped between the jib and the wagon end as the train moved, receiving fatal injuries.

Conclusions

The formal inquiry panel concluded that the immediate cause of the accident was due to the train being given authority to move while still unloading. The underlying causes were identified as:

• The belief of controllers of two road rail vehicles, that they had authority to resume unloading work after the train stopped.
• Creation of the position of engineering supervisor assistant, a role not recognised by the Rule Book, to assist the engineering supervisor in controlling the movements of the trains and road rail vehicles in the work site. It effectively created two engineering supervisors operating within the work site with consequent communication and responsibility problems.
• Inadequate planning and arrangements for communication on site. The engineering supervisor not being told, or overlooking the fact, that only three out of the five controllers had radios with which to receive instructions.
• Possibly the use of cannabis by the labourer may have affected his ability to react quickly to the driver of the train sounding the locomotive warning horn and the movement of the train.

Recommendations

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

• Review of the production of work plans to ensure clear understanding by all staff involved.
• Information contained in workplans should accurately represent situation found on site.
• Review of risk assessment used in conjunction with work plan.
• Control measures recognised during work planning process.
• Method statements prepared for repetitive site work should be cross-referenced with work plan.

The Rail Safety and Standards Board 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. The Rail Safety and Standards Board will track the industry's response to this report.