Formal Inquiries

Hednesford report and recommendations

Rail Safety and Standards Board (RSSB) has issued its formal inquiry report into the circumstances that led to a fatal accident within a worksite between Cannock and Hednesford on 28 September 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

The initial stage of a project to relay a section of the Up line between Cannock and Hednesford involved delivery of the rail during a T3 possession, planned for 0045 hrs to 0540 hrs, 28 September 2004. Network Rail (NR) Rail Delivery Train (RDT) loaded with 23 216m lengths of continuous welded rail (CWR) had positioned ten pairs of the rails as a continuous sequence in the four-foot of the Down line. A road-rail vehicle (RRV) was following the RDT but operating from the Up line to reposition the rails to ensure that they were not lying above the running rails where excess ballast was present.

A footpath crossing and a crossover prevented the remaining three rail lengths being unloaded immediately beyond the tenth pair. The RDT was set back by two rail lengths, 432m, to unload the 11th pair of rails adjacent to the ninth pair and the last rail adjacent to the tenth pair of rails.

The RDT is approximately 300m long, during the reversing move most of the train passed the stationary RRV, coming to rest with the RRV to the rear of the locomotive, somewhere alongside the first vehicle of the RDT. The intention was that the RRV would remain stationary on the Up line during the unloading of the 11th pair of rails.

Unloading of the 11th pair of rails was nearly completed when the RRV was reversed back along the RDT striking and fatally injuring two of the RDT operatives. They were observing the unloading of the final few metres of the rails from the adjacent four-foot.

Conclusions

Immediate Causes
Two operatives of a Rail Delivery Train who were standing in the four-foot were struck and fatally injured by a road-rail vehicle that was making a reversing movement.

Underlying Causes
Lack of a documented workplan to assist staff responsible for site safety in understanding the tasks to be undertaken, establishing a safe system of work and communicating planned procedures to the other staff on site.

Planning the work through two independent method statements that were not brought together at any point before the work was carried out.
A method statement production process which did not give a realistic time for it to be checked or reviewed within the organisations of either the contractor or client.

Operating a single worksite with two trains and five road rail vehicles without effective communication arrangements between the engineering supervisor and the machine controllers.

Making changes to the plans for rail delivery, during the operation, without fully understanding or explaining the implications to all site staff affected and not ensuring that the changes had been understood.

Permitting a reverse movement of a road-rail vehicle with the machine not correctly illuminated and the controller not in a position to see the track ahead and maintain communication with the operator.

Operating a worksite with three groups of workers without a COSS being appointed for each workgroup.

Allowing the movement of trains and RRVs without all the instructions being communicated by the engineering supervisor.

Recommendations

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

Progress on production of method statements should be monitored as a specific item of the project planning process. If method statements are not available in time to allow a realistic period for review and acceptance prior to the method statement being used as a basis for preparation of the site briefing documents, the project should be deferred.
The method statement should cover all activities undertaken in a worksite, including those of the principal contractor, sub contractors and any other organisations associated with the project in compliance with the CDM regulations.
Inspections carried out to establish local constraints, conditions and hazards for recording on forms RDS001 and RDS002 should be undertaken sufficiently far in advance for the information to be included in the project method statement.
When site staff are obtained from labour supply organisations, sufficient notice should be provided, together with a meaningful outline of the intended duties, so that both the supply organisation and the contractor can assess the necessary abilities and experience required of the individuals.
The briefing arrangements for a project should be based on its complexity and the potential hazards likely to be encountered by staff. When it is not practicable to brief staff on the work hazards and control measures prior to arrival on site, additional time should be allowed before the start of work for a detailed briefing of all site staff to be delivered and recorded.
A review of module T3 and T7 of the rule book should be undertaken to establish safe systems of work which accommodate multiple activities and train movements within worksites.
One of the RDT operatives should always act as COSS for the rail delivery process. The COSS should previously have undertaken the pre-delivery site inspection and gathered relevant local safety information The RDT method statement should be amended to reflect this method of work.
Machine Controllers’ safety responsibilities, duties, methods of working and communicating as expressed in the various rule book modules, RGSs, related NR company standards and M&EE COPs should be reviewed. Clarity should be provided on what is required and how it is to be achieved when controlling RRVs during travelling movements and working operations.
The plan to register machine controllers under the Sentinel scheme is an important site safety initiative. Appropriate steps should be taken to ensure that the target implementation date of 4 April 2005 is achieved.
Communication methods and the equipment and protocol to be used by the ES, COSS(s) and MC(s) should be documented as part of the method statement and briefed to all site staff at the start of work for the activities to be undertaken.
The RDT risk assessment should be reviewed to address degraded mode working and the relevant control measure included in the method statement.
The situations in which it will be necessary to reposition rail delivered by the RDT should be documented and communicated as guidance to all relaying contractors.
Contract staff offered employment on safety critical work on NR infrastructure should be actively questioned about any other planned work commitments and previous duties to ensure they take the requisite rest periods. Responses should be recorded.
When the rail delivery plan devised during the pre-delivery site inspection is changed, the new arrangements must be authorised by the ES and communicated to the other site COSSs. Plan change should be included in the RDT risk assessment and the method statement amended.
Pre-tender health and safety plans issued by NR as tender documentation for track renewals contracts should be reviewed to ensure that all site processes are covered including supply and delivery of materials by NR and their direct contractors.

Similarly the construction phase health and safety plan developed from the tender documentation should be reviewed to encompass all organisations involved in the project.

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.