Formal Inquiries

Ancaster report and recommendations

Rail Safety and Standards Board (RSSB) has issued its formal inquiry report into the circumstances that led to the fatality of a track worker at Ancaster on 5 March 2004.

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

Mowlem Railways was engaged as a contractor to Network Rail to carry out re-sleepering of sections of track between Grantham and Skegness.

Re-sleepering was being undertaken at two locations near to Ancaster Station. When the work at the site east of Ancaster finished, a convoy of on-track plant (OTP) proceeded along the line to the off-tracking location at Ancaster Station. It was during this movement that the boom and bucket of a road-rail excavator was in collision with the rear of a sleeper-adjusting machine, which had stopped during transit. A number of track workers had been travelling, irregularly, on the exterior of the sleeper-adjusting machine, which was partially derailed in the collision. Some of the track workers fell, or jumped or were thrown off and one who sustained injuries in the collision, then fell heavily.

The injured man was conscious when examined by the ambulance crew but his condition deteriorated. He was taken to hospital where he died a short time later from the injuries he had sustained.

Conclusions

The formal inquiry panel concluded that the immediate cause of this accident was the collision between on-track plant (OTP), which resulted in the fatality of a trackman.

The panel also concluded that the the following were deemed to be underlying causes:

• The decision to withdraw a man basket from use before the completion of work.
• The design of lighting on both vehicles was not adequate for purpose.
• The speeds for transit of OTP within the worksite, but away from the place of work, were not at caution in accordance with module T11 of the Rule Book.
• Modules OTP and T11 of the Rule Book fail to address the operation of a number of items of OTP in one worksite, and the safe management of the movement of these items of OTP within the worksite.

Recommendations

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

• Re-issue and reinforce the instructions relating to the prohibition of staff riding on OTP.
• Make provision during work planning for suitable and adequate arrangements for the transport of staff required to accompany or work with OTP.
• OTP be clearly marked with the maximum speed of that particular OTP. If a lesser speed is applicable within a worksite, this must also be displayed.
• All OTP should be fitted with speedometers.
• Review the adequacy of the headlights and taillights on all OTP, to ensure that operators have adequate forward vision when travelling in darkness, and that taillights are of adequate size and are positioned at a height above rail level to be in the line of vision of the operator of following OTP.
• Review the rules applicable to the operation of more than one item of OTP within a worksite, in a T3 possession. The review should include consideration of speed of movements, and a robust system for maintaining a separation distance between individual machines within the worksite.

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