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Summary
At about 01:40 hrs on Friday 8 June 2018, a road-rail vehicle (RRV) ran away while being on-tracked at a road-rail access point south of Bradford Interchange station. The RRV ran downhill for approximately 340 metres, before coming to a stop as the track levelled out in the station. The RRV’s machine operator and machine controller were able to run along with it and warned a member of track maintenance staff, who was able to move clear in time.
The RRV ran away because its rail wheels were, incorrectly, partially deployed and because the rail wheel braking system had not been correctly maintained.
Partial deployment of the rail wheels was a result of the machine operator not following the standard industry procedure for on- and off-tracking. He had routinely been on- and off-tracking in this manner and this had not been detected by his employer, Readypower.
The braking system on the rail wheels had not been correctly maintained because fitters were not following the original equipment manufacturer’s instructions and Readypower had not detected this.
An underlying factor was that the industry’s competence management system for machine operators focuses on the renewal of qualifications, rather than demonstrating ongoing competence.
Recommendations
The RAIB has made three recommendations. The first one seeks to improve the industry’s competence management system for all machine operators who work on Network Rail’s infrastructure. The second, addressed to Readypower, is intended to improve the management of competence of its staff. The last recommendation aims to improve the quality of the maintenance instructions and training provided to Readypower’s fitters.
Simon French, Chief Inspector of Rail Accidents said:
“Getting road-rail plant safely on and off the track ought to be a straightforward business. Unfortunately, over the years RAIB has had to investigate too many incidents in which this operation has gone wrong, and the machine involved has run away downhill, often for quite long distances. Too often the people in charge have not known what to do to stop the runaway. In this case, the machine operator’s actions were not in line with what he had been trained to do, and no-one had checked on him. Of greater concern, however, is that the machine’s brakes did not hold it stationary on the 1 in 46 gradient. This was because they were badly maintained, a state of affairs that can be traced back to poor instructions and inadequate supervision of the plant hire company’s maintenance staff.
“The management of safety in the rail plant industry is something that RAIB has expressed concern about before. In the past, one of the important issues has been the competence of machine operators and maintainers. In this case, the problems were not only at the plant hire company. The project to convert many road-rail vehicles to direct rail wheel braking also lacked important elements of safety assurance, such as provision for proper information about the machines being converted, and adequate arrangements for training the people who would have to maintain the new braking systems.
“This incident provides an opportunity for the industry to learn major lessons from a relatively minor event. Our recommendations are directed to Network Rail and one other company, but I hope that people in all areas of the rail plant sector will take note of the learning points in this report, and make sure that their company safety management systems are comprehensive and fully implemented.”
Notes to editors
- The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.
- RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.
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Newsdate: 14 March 2019