Formal Inquiries

Slade Lane Junction report and recommendations

Rail Safety and Standards Board (RSSB) has issued its formal inquiry report into the circumstances that led to a track worker coming into contact with live overhead line equipment (OLE) on 29 June 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 the project to upgrade the West Coast main line, work was planned to take place on the overhead line equipment in the Slade Lane Junction area. This work was programmed to take place, alongside other track work, during a one week blockade.

The possession had commenced and the works were proceeding to plan. On the night of 28/29 June an OLE team arrived on site where they intended to carry out work involving the disconnection of a booster transformer mounted on a steel structure and make some alterations. During this work, an OLE linesman climbed to the top of the 8m high structure and as he was preparing to secure his safety harness he came into contact with live equipment.

He received a severe electrical shock, and as a result, was thrown from his position at the top of the structure to the ground, where he struck the leg of one of his colleagues and landed heavily on his side. He sustained electrical burns and a broken left leg.

The injured person was attended on site by a first-aider from the OLE team until paramedic staff arrived and he was taken to hospital.

Conclusions

The formal inquiry panel concluded that the OLE worker was injured whilst working near a cable sealing end that remained live after the OLE isolation was taken.

The panel also concluded that there were a number of underlying causes including:

• Lack of clarity concerning the responsibility for determining and authorising specific work content and implementation method.
• Use of generic method statements and lack of site-specific risk assessment and method statements for work in a complex area.
• Changes to the work content were made without planners or project management being aware
• Very late changes were accepted, causing changes to the OLE isolation plan and misunderstandings between project management, planners and ECR staff about how the isolation for the work would be achieved.
• Lack of competence of persons allocated to site safety roles.
• The completed isolation form (Form C) lacked specific details of the work and no mention in the remarks column of OLE equipment that would remain live.
• Confusion existed about the meaning of the term ‘complete’ isolation.

Recommendations

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

• Project management and planning arrangements should be reviewed to ensure clarity of roles, responsibility and authority to agree work content and implementation arrangements.
• Appropriate training standards, competence assessments and certification requirements should be established for COSS and OLE work.
• · The isolation instructions for OLE should be revised, re-issued and re-briefed.

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.