Report 11/2022: Collision between a passenger train and a hand truck at Challow

R112022_221013_Challow

This file may not be suitable for assistive technology users.

Ask for an accessible format.


If you use assistive technology (such as a screen reader) and need a version of this document in a more accessible format, please email [email protected] Please let us know which format you need. It will help us if you say what assistive technology you use.

Summary

At 6.09am on October 21, 2021, a passenger train traveling at 123mph (198kph) struck a hand truck on the track near Callow, Oxfordshire. The train was the first to pass through the area after the completion of overnight maintenance work. There were no injuries to passengers or crew on board and the train did not derail. The dolly was destroyed by the impact and the debris from it caused damage to the equipment under the train. The collision also caused minor damage to the track.

A maintenance crew had been doing night work at Challow and no one had noticed that the crew had left their hand truck on the track. The checks carried out before returning the railway to normal operation had also not identified the presence of the devil. One process that was part of these checks was the free line check process. It was used to monitor which vehicles, including hand trucks, were placed in and out of the lane during night work. However, there were weaknesses in this process, and these were compounded by the fact that the maintenance team did not follow the process as required on the night in question.

The underlying factors related to the weaknesses of the clear line verification process were:

  • It depended on human actions for its successful implementation, which the railway industry had recognized, but had not yet implemented any measures to avoid or mitigate errors.
  • It was separate from the work planning process as defined by Network Rail’s corporate standards. It was a possible underlying factor.
  • Network Rail’s assurance business had failed to detect that staff in the welding and grinding section of the Swindon delivery unit were not complying with the line check process. It was a possible underlying factor.

Another likely underlying factor was that hand trucks were routinely operated at night without running red lights and no insurance activity took place at work sites to monitor compliance with this requirement.

The RAIB notes that after the accident, the train was authorized to travel at a higher speed than that which should have been authorized given the extent of the damage it had suffered. RAIB also observed that there were several issues with the way work at Callow was planned by Network Rail.

Recommendations

The RAIB made five recommendations to Network Rail. The first is to establish how the existing free line verification process can be improved while the second is to consider what technology could be used by its staff to support the process. The third recommendation is to propose an amendment to the regulations so that hand trucks are required to display a red light on in both directions at all times while on the track. The fourth is for Network Rail to put processes in place to ensure that any hand truck placed on its track has red lights on displayed in both directions. The fifth recommendation is to review the effectiveness of its safety assurance activities that verify that hand trucks are used correctly and safely.

The RAIB also identified three learning points. The first reminds maintenance staff of the importance of complying with all rules and standards regarding the use of trolleys and track sliders on Network Rail infrastructure. The second stresses the importance of clear communication between personnel on a train involved in an accident and those based in control rooms to establish what damage has been sustained by a train, so that appropriate controls can be put in place. place before the train is allowed to move. The third is that the personnel involved in the planning of maintenance work produce documents that are accurate, appropriate and specific to the task being carried out, and involve those responsible for the work in the planning of the work.

Chief Rail Accident Inspector Andrew Hall said:

Systems and processes designed to detect any equipment left on the track before lines reopen after maintenance work should not rely solely on human performance in the middle of a dark night. There are technological solutions that can help solve this problem, and this accident is an example of a missed opportunity.

Our investigation revealed that the railway had identified the risk of equipment, such as hand trucks, being left on the line and could mitigate this risk by improving the line clearance verification process. However, he had not yet implemented the required changes when this accident occurred. This meant that the process remained vulnerable to human error. In this case, this vulnerability was compounded because the relevant procedures were not followed correctly. Technology has an important role to play in improving railway safety and it is important that developing solutions to better support staff is a priority.

It is also of concern that hand trucks are routinely used on the runway at night without displaying red lights. But it is equally concerning that no monitoring activity of this requirement has been undertaken. Again, assurance activities to verify that rules are followed and processes are correctly implemented have not been effective.

Notes to Editors

  1. The sole purpose of RAIB investigations is to prevent future accidents and incidents and to improve railway safety. The RAIB does not establish fault, liability and does not take legal action.

  2. The RAIB operates, as far as possible, in an open and transparent manner. Although our investigations are completely independent of the railway industry, we maintain close liaison with the railway companies and if we discover any issues that could affect railway safety, we ensure that the information to their topic is broadcast to the right people as soon as possible. , and certainly well before the publication of our final report.

  3. For media enquiries, please call 01932 440015.

News date: October 13, 2022

Jose P. Rogers