Report 18/2018: Runaway hand trolley at Ramsbottom
RAIB has today released its report into a runaway hand trolley at Ramsbottom, East Lancashire Railway, on 15 March 2018.
Ramsbottom station level crossing
Summary
At around 11:15 hrs on Thursday 15 March 2018 a hand trolley, loaded with approximately 0.5 tonnes of ballast, ran away from a group of track workers near to Ramsbottom station on the East Lancashire Railway. The trolley derailed when it struck a wooden level crossing gate. The gate was pushed into a road which was open to road traffic.
There were no injuries, although the level crossing gate was damaged.
The immediate cause of the runaway was that the trolley was not fitted with any brakes and was deployed on a gradient without the introduction of any mitigation or safeguard against it running away.
The unbraked trolley was almost certainly available for use because it had been donated to the East Lancashire Railway, which did not have any processes in place to manage donations, and no controls in place for use of trolleys during track maintenance. Additionally, there were no constraints on the use of such trolleys on the railway, nor any competence and training requirements for their operators.
There was no assessment of the risks of using the trolley, either generically or for the specific task on the day, and there was no formal training or briefing of the operators on the day.
The underlying factors were inadequate management systems in the Permanent Way department and, probably, a lack of Safety Management System compliance audits.
Recommendations
The RAIB has made three recommendations as a result of this investigation. The first is made to the Heritage Railway Association and relates to it issuing guidance to its members on limiting the use of trolleys not fitted with fail-safe brakes, and fully assessing the risks where they are to be used. The other two are made to East Lancashire Railway; the first relates to the provision of suitable working procedures in the Permanent Way department, and the other to the implementation of an effective audit process.
The RAIB has also identified three learning points. These relate to the importance of undertaking planned audit and compliance activities; being clear about how vehicles and trolleys are to be controlled before they are deployed; and considering the safety risks associated with assets that are acquired through donations.
Notes to editors
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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.
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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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