Recommendation Status Report: Runaway wagon at Kineton, Warwickshire
This report is based on information provided to the RAIB by the relevant safety authority or public body.
The status of the recommendation(s), as reported to us, are described by the following categories:
Key to Recommendation Status
Open Actions to address the recommendation are ongoing.
(replaces Progressing and
Implementation On-going)
Closed ORR consider the recommendation to have been taken into consideration by an end implementer and
(replaces Implemented, Implemented evidence provided to show action taken or justification for no action taken.
by alternative means, and Non-
implementation)
Insufficient response: The end implementer has not provided sufficient evidence that the recommendation has been taken into
consideration, or if it has, the action proposed does not address the recommendation, or there is
insufficient evidence to support no action being taken.
Superseded: The recommendation has been superseded either by a newer recommendation or actions have
subsequently been taken by the end implementer that have superseded the recommendation.
Awaiting response: Awaiting initial report from the relevant safety authority or public body on the status of the
recommendation.
RAIB concern over the way that an organisation has responded to a recommendation are indicated by one of the following:
Red – RAIB has concerns that no actions have been taken in response to a recommendation.
Blue – RAIB has concerns that the actions taken, or proposed, are inappropriate or insufficient to address the risk identified during the investigation.
White – RAIB notes substantive actions have been reported, but the RAIB still has concerns.
Recommendation Status Report
Report Title Runaway wagon at Kineton, Warwickshire
Report Number 04/2024
Date of Incident 25/05/2023
Rec No. Status RAIB Concern Recommendation RAIB Summary of current status
04/2024/01 Awaiting Response None The intent of this recommendation is to ensure that the Ministry of
Defence is safely managing the risks involved with defence rail operations.
The Ministry of Defence should review the arrangements by which it
conducts railway operations on behalf of the Secretary of State for
Defence. This review should consider:
i. If there is a full understanding of the extent and type of current defence
rail operations, including interfaces with contractors and parties external
to the Ministry of Defence, such as the mainline railway and the Office of
Rail and Road.
ii. If an appropriate organisation exists to safely manage the various
elements involved in defence rail operations, including clear governance
structures, roles and accountabilities and the safety assurance of relevant
contractors (including appropriate escalation routes for contractors raising
safety related matters).
iii. If this organisation is correctly resourced with the Ministry of Defence
and its contractors, with appropriately trained and competent staff
occupying key roles.
iv. If up-to-date and appropriate risk assessments are in place for all
elements of defence rail operations, including the stabling of wagons on
the sites where it is the infrastructure manager. These risk assessments
should specifically consider the risks that defence rail operations can
present to the public, Ministry of Defence staff, contractors, and the
mainline railway.
v. If an appropriate safety management system, operating rule book and
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Recommendation Status Report
other supporting technical standards are in place and if these documents
include the appropriate control measures needed to address risk and good
practice in other parts of the rail industry.
vi. How safety related documents are made available to staff working for
the Ministry of Defence and its contractors.
vii. How the Ministry of Defence takes account of appropriate safety
learning from sources such as internal investigations and safety learning
from the wider rail industry.
Following this review, the Ministry of Defence should develop a
timebound plan to make any appropriate changes identified to working
practices, processes and organisational structure (paragraphs 188a, 188c,
188c.i, 188d, 188d.i and 189b).
04/2024/02 Awaiting Response None The intent of this recommendation is to ensure that there is a clear
understanding of the regulatory arrangements applying to railways
operated on behalf of the Secretary of State for Defence.
The Defence Safety Authority of the Ministry of Defence should agree the
roles and responsibilities for safety regulation of defence operated
railways with the Office of Rail and Road and any other relevant statutory
safety regulators to ensure they are clearly defined.
Following this agreement, the parties involved should consider their
respective regulatory strategies, ensuring that there are adequate
resources in place to meet their regulatory obligations (paragraph 189c).
04/2024/03 Closed - I None The intent of this recommendation is to ensure that Kuehne+Nagel is
managing the risks involved with its defence rail operation.
Kuehne+Nagel should review its delivery of railway operations on behalf
of the Secretary of State for Defence. This review should consider:
i. If Kuehne+Nagel fully understands the extent and type of rail operations
which it undertakes for the Ministry of Defence.
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ii. If an appropriate organisation exists to safely manage the various
elements of defence rail operations for which Kuehne+Nagel is
responsible, including clear governance structures, roles and
accountabilities and safety assurance.
iii. If this organisation is correctly resourced within Kuehne+Nagel with
appropriately trained and competent staff occupying key roles.
iv. If up-to-date and appropriate risk assessments are in place for all
elements of Kuehne+Nagel’s defence rail operations, including the
stabling of wagons on sites where it is responsible for rail operations.
These risk assessments should specifically consider the risks that its rail
operations can present to the public, staff and the mainline railway.
v. If an appropriate safety management system, operating rules and other
supporting technical standards are in place and if these documents
include the appropriate control measures needed to address risk and good
practice in other parts of the rail industry.
vi. How safety related documents are made available to staff working for
Kuehne+Nagel.
vii. How Kuehne+Nagel takes account of appropriate safety learning from
sources such as internal investigations and safety learning from the wider
rail industry.
Following this review, Kuehne+Nagel should develop a timebound plan to
make any appropriate changes identified to working practices, processes
and organisational structure (paragraphs 188a, 188b, 188c, 188c.i, 188c.ii,
188d, 188d.ii, and 189a).
04/2024/04 Closed - I None The intent of this recommendation is to improve the maintenance regime
applied to FAA wagons.
DB Cargo should review the maintenance procedures relating to FAA
wagons at Carlisle Kingmoor depot. This review should include:
i. A review of the effectiveness of the current arrangements for the visual
inspection and brake test of FAA wagons and if they ensure that
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handbrake cables are appropriately inspected.
ii. Consideration as to how visual inspection and brake tests of wagons at
Carlisle Kingmoor depot can be improved to make it more effective at
detecting cables which may be worn and/or approaching the end of their
service life. This should include the type and suitability of the facilities
used for such inspections.
iii. Examining how the results of visual inspection and brake tests are
recorded.
Following this review, DB Cargo should develop a timebound plan to make
any appropriate changes identified to working practices, processes and
facilities (paragraphs 188c, 188c.iii).
04/2024/05 Closed - I None The intent of this recommendation is to reduce the likelihood of a life
expired safety-critical brake component being left in place on an
operational wagon.
DB Cargo should review the basis on which it determines the replacement
of brake component parts fitted to wagons to ensure that those which are
beyond their effective service life are identified and scheduled for
replacement at appropriate intervals, considering both time-based and
mileage-based intervals.
This recommendation may be applicable to other entities in charge of
maintenance (paragraphs 188c, 188c.iii and 190a).
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