Rail Safety and Standards Board (RSSB) has issued its formal inquiry report into the circumstances that led to the fatality of a contractor at Fareham No. 2 Tunnel on 14 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
As part of a programme of structures examination, work was in progress to inspect a vertical shaft above Fareham No2 Tunnel using rope access techniques.
To facilitate this inspection four employees of two contracting companies were engaged in removing a section of a prefabricated steel cover that sat atop the shaft. Following a rudimentary inspection by both groups, it was concluded that the cover could be partially removed to facilitate access by abseilers.
Believing that all the quadrants were supported underneath by at least one structural cross-member, the men removed the nuts securing one quadrant to the others. However, as one of the men stood up after removing the last bolt of the quadrant section on which he was standing, it pivoted and he fell into the shaft and down to track level, some 26 metres below, where he suffered fatal injuries.
Conclusions
The formal inquiry panel concluded that the rope access technician fell down the ventilation shaft when an unsupported quadrant section of the cover collapsed, following removal of the nut and bolt fixings which attached the quadrant sections together.
The panel also concluded that there were a number of underlying causes including:
Changes to contractual arrangements in January 2004 affecting the procurement of enabling works to support the shaft examination programme.
Management and coordination arrangements on site were both unclear and insufficient.
No risk assessment or method statement had been compiled for the removal of the cover.
Liaison between contractors prior to the possession was inadequate.
The reconnaissance visit failed to identify the shaft cover as an
issue, because the visit had entailed only a tunnel walk through.
Recommendations
The report makes recommendations for improvements in a number of key areas and these are summarised as follows.
A review of the arrangements by which terms and conditions within formal contracts may be changed or varied should be undertaken.
The extent to which the principles and disciplines of the Construction (Design and Management) regulations(CDM), especially in the areas of roles and responsibilities, and management competence, can be introduced into non-CDM projects should be considered.
The reconnaissance requirements laid down in Network Rail Standard RT/CE/S/017 Section 8 should be adhered to for all detailed structures examinations.
The requirement for fall prevention and/or fall protection equipment to be used at all times when working on, around or near tunnel shafts should be reviewed and mandated where necessary.
The requirement for method statements to be relevant and specific to the actual work being undertaken, and to the site of that work, should be reinforced within the industry.
A process should be established to link emergency works to stored knowledge about the asset to:
Provide assurance regarding the fitness of the works
Ensure a record of all works undertaken
Ensure change to the asset is included in the asset database
The processes by which knowledge about assets is gathered, recorded, and updated, to ensure the information is current and in usable form should be reviewed.
Standard replacement cover designs for tunnel shafts, which recognise modern rope access techniques and which no longer require personnel to access shafts through the shaft cover should be considered.
The management and control processes for scoping, procurement, authorisation and monitoring of minor works should be reviewed, to ensure that approvals arrangements are appropriate to the nature of the work to be undertaken.
RSSB 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. RSSB will track the industry's response to this report.
