Rail Accident Report
Collision between a road-rail vehicle and a
trolley near Brading, Isle of Wight
22 November 2023
Report 12/2024
October 2024
This investigation was carried out in accordance with:
• the Railway Safety Directive 2004/49/E C
• the Railways and Transport Safety Act 2003
• the Railways (Accident Investigation and Reporting) Regulations 2005.
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This report is published by the Rail Accident Investigation Branch, Department for Transport.
Preface
Preface
The purpose of a Rail Accident Investigation Branch (RAIB) investigation is to
improve railway safety by preventing future railway accidents or by mitigating their
consequences. It is not the purpose of such an investigation to establish blame or
liability. Accordingly, it is inappropriate that RAIB reports should be used to assign
fault or blame, or determine liability, since neither the investigation nor the reporting
process has been undertaken for that purpose.
RAIB’s findings are based on its own evaluation of the evidence that was available at
the time of the investigation and are intended to explain what happened, and why, in a
fair and unbiased manner.
Where RAIB has described a factor as being linked to cause and the term is
unqualified, this means that RAIB has satisfied itself that the evidence supports both
the presence of the factor and its direct relevance to the causation of the accident or
incident that is being investigated. However, where RAIB is less confident about the
existence of a factor, or its role in the causation of the accident or incident, RAIB will
qualify its findings by use of words such as ‘probable’ or ‘possible’, as appropriate.
Where there is more than one potential explanation RAIB may describe one factor as
being ‘more’ or ‘less’ likely than the other.
In some cases factors are described as ‘underlying’. Such factors are also relevant
to the causation of the accident or incident but are associated with the underlying
management arrangements or organisational issues (such as working culture).
Where necessary, words such as ‘probable’ or ‘possible’ can also be used to qualify
‘underlying factor’.
Use of the word ‘probable’ means that, although it is considered highly likely that the
factor applied, some small element of uncertainty remains. Use of the word ‘possible’
means that, although there is some evidence that supports this factor, there remains a
more significant degree of uncertainty.
An ‘observation’ is a safety issue discovered as part of the investigation that is not
considered to be causal or underlying to the accident or incident being investigated,
but does deserve scrutiny because of a perceived potential for safety learning.
The above terms are intended to assist readers’ interpretation of the report, and to
provide suitable explanations where uncertainty remains. The report should therefore
be interpreted as the view of RAIB, expressed with the sole purpose of improving
railway safety.
Any information about casualties is based on figures provided to RAIB from various
sources. Considerations of personal privacy may mean that not all of the actual effects
of the event are recorded in the report. RAIB recognises that sudden unexpected
events can have both short- and long-term consequences for the physical and/ or
mental health of people who were involved, both directly and indirectly, in what
happened.
RAIB’s investigation (including its scope, methods, conclusions and recommendations)
is independent of any inquest or fatal accident inquiry, and all other investigations,
including those carried out by the safety authority, police or railway industry.
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Report 12/2024 4 October 2024
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Collision between a road-rail vehicle and a
trolley near Brading, Isle of Wight, 22 November
2023
Contents
Preface3
Summary7
Introduction8
Definitions 8
The accident9
Summary of the accident 9
Context10
Background information16
The sequence of events17
Events preceding the accident 17
Events during the accident 21
Events following the accident 23
Analysis25
Identification of the immediate cause 25
Identification of causal factors 25
Identification of underlying factors 30
Observations31
Summary of conclusions 34
Immediate cause 34
Causal factors 34
Underlying factors 34
Additional observations 35
Actions reported as already taken or in progress relevant to this report36
Actions reported that address factors which otherwise would have resulted
in an RAIB recommendation 36
Recommendations and learning points37
Recommendations37
Learning points 38
Report 12/2024 5 October 2024
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Appendices39
Appendix A - Glossary of abbreviations and acronyms 39
Appendix B - Investigation details 40
Report 12/2024 6 October 2024
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Summary
Summary
At around 01:50 on Wednesday 22 November 2023, a road-rail vehicle, travelling
in a work site, collided with a hand trolley being used by a work group on the Isle of
Wight’s Island Line. The road-rail vehicle was being used to clear vegetation and was
travelling between its work locations when the collision occurred.
The road-rail vehicle was approaching the work group, who were repairing the track,
on a descending gradient and was unable to stop before their site of work. When
members of the work group realised that the road-rail vehicle was not stopping, they
removed tools and equipment from the trolley and lifted it off the track. However, once
removed, the trolley was inadvertently left too close to the track and remained foul of
the road-rail vehicle’s path. The road-rail vehicle then collided with the hand trolley.
As a result of the collision, the trolley struck two members of the track repair work
group on the legs, pushing them into bushes beside the track. Both received minor
injuries, attended hospital independently later that day and were then discharged.
The collision was caused because the controller of site safety responsible for the
track work group had not been informed of the road-rail vehicle’s movement before
it approached, and because the road-rail vehicle was unable to stop in the expected
distance once the machine operator realised the work group was ahead.
Two underlying factors were that South Western Railway, the infrastructure manager
for the track on the Island Line, did not have an effective process for planning and
managing the risk of on-track plant movements, or for managing low adhesion
risk for maintenance activities. A third underlying factor was that South Western
Railway’s assurance processes had not identified informal working arrangements in
possessions.
Since the accident, South Western Railway has updated its risk assessment for
machine movements and introduced new control measures to specifically manage
the risks of conflicting sites of work within work sites and possessions. It has also
addressed the deficiencies found within its assurance process for monitoring how
possessions are managed.
As a result of the investigation, RAIB has made three recommendations, all
addressed to South Western Railway. The first is to review how it manages safety
during infrastructure work on the Island Line. The second is to review its assurance
processes and the third is to provide its infrastructure maintenance staff and
contractors with accurate information about its infrastructure.
Additionally, three learning points have been identified. The first reinforces the
importance of transport undertakings and on-track plant operators applying industry
codes of practice in the event of an accident or incident involving on-track plant. The
second concerns the importance of promptly reporting notifiable accidents to RAIB,
and the third the importance of well-established process and procedure for dealing
with post‑accident or incident evidence collection and testing.
Report 12/2024 7 October 2024
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Introduction
Introduction
Definitions
1 Metric units are used in this report, except when it is normal railway practice to
give speeds and locations in imperial units. Where appropriate the equivalent
metric value is also given.
2 The report contains abbreviations and acronyms, which are explained in appendix
A. Sources of evidence used in the investigation are listed in appendix B.
Report 12/2024 8 October 2024
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The accident
The accident
Summary of the accident
3 At around 01:50 on Wednesday 22 November 2023, a road-rail vehicle
(RRV) weighing approximately 30 tonnes collided with a hand trolley between
Smallbrook Junction and Brading on the Isle of Wight’s Island Line (figure 1).
4 At the time of the accident, the Island Line was under possession and closed to
normal rail services. The possession occurred during the 5th week of a 6-week
major maintenance programme which saw overnight working involving additional
track maintenance staff contracted in as well as the normally employed workforce,
and equipment brought over from the mainland. The hand trolley was being used
by a track repair work group to transport tools and equipment.
5 The collision occurred on a descending gradient. The RRV’s machine operator
(MO) saw the stationary hand trolley and intended to stop their vehicle a short
distance from it to allow members of a track repair work group to lift the trolley
off the track. However, when the MO attempted to slow the RRV, its rail wheels
stopped rotating and started to slide. The RRV’s speed did not immediately
reduce so the MO sounded the horn to give a warning. The MO and machine
controller (MC), who was travelling in the rear of the RRV cab, repeatedly shouted
a warning to the work group ahead of them.
6 When the members of the work group realised that the RRV was not stopping,
they quickly removed tools and equipment from the trolley and lifted it off the
track. They then put the trolley down close to the track.
7 As the RRV passed at low speed, its leading right-hand rubber tyre struck a
corner of the trolley, causing it to spin round. The trolley struck two members of
the track repair work group on the legs. They were pushed into adjacent bushes,
either after being directly struck or struck by the other person, with the trolley
then landing on one person’s legs. An ambulance was not required, but both staff
members involved independently attended hospital later on 22 November after
returning to the mainland. One person was diagnosed with a muscle injury to
the upper back and soft tissue injury to the legs. The other was diagnosed with a
minor head injury. Both were discharged the same day.
8 Neither the RRV nor the hand trolley were damaged in the accident. Witness
evidence indicates that the RRV eventually stopped around 100 metres beyond
the point of collision.
Report 12/2024 9 October 2024
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The accident
Location of accident
Contains Ordnance Survey data: @Crown Copyright and database right 2024.
OS license number: AC0000833184. Source: Department for Transport, RAIB 2024
Figure 1: Extract from Ordnance Survey map showing location of accident near Brading.
Context
Location
9 The Island Line is a standard gauge railway that runs for 8 miles 31 chains
(13.5 km) between Ryde Pier Head and Shanklin on the eastern side of the Isle of
Wight. There are six intermediate stations (figure 2).
10 The accident occurred at 3 miles 37 chains (from a reference point at Ryde
Pier Head station), on the line between Smallbrook Junction and Brading. On
the Island Line, small metal plates are attached to some sleepers showing the
location in miles and chains. There are 80 chains in a mile; each chain is 22
yards (20 metres). The single‑track approach to this location, when travelling in
the down direction towards Shanklin, is a left-hand curve with a falling gradient of
1 in 78.
Organisations involved
11 Network Rail is the owner of the Island Line’s infrastructure and maintains its
structures (such as bridges) and signalling. It is not responsible for maintaining
the track or stations which are leased to South Western Railway (SWR).
12 SWR is a train operating company which operates rail services between London
and the South/South-West of England. It is also the train operating company for
the Island Line and infrastructure manager for its stations and track. It holds a
lease to operate, maintain and renew Island Line infrastructure from Network
Rail. It was the employer of the person in charge of possession (PICOP), the
engineering supervisor (ES) in charge of the work site, and the controller of site
safety (COSS) involved in the accident.
Report 12/2024 10 October 2024
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The accident
Ryde Pier Head
N
Ryde Esplanade
Ryde St Johns Road
depot
1 mile (0.6 km)
Smallbrook Junction
Accident location
3 miles 37 chains
Brading
Sandown
Sandown yard
Lake
Milepost
Station
Shanklin
Figure 2: Simplified diagram showing Island Line route.
13 Sonic Rail Services (SRS) was the contracted supplier of the RRV and employer
of the MO and MC.
14 SGC Rail Solutions Ltd (SGC) was the contracted agency supplying track
maintenance staff, including those who were struck by the trolley. The Companies
House website states that SGC Rail Solutions is now in liquidation.
15 These organisations freely co-operated with the investigation.
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Rail vehicles involved
The accident
16 The RRV is equipped with rubber tyres and rail wheels and has a gross vehicle
weight of 30.16 tonnes (figure 3). It is a Type 9A machine with its rail wheels
powered by a hydrostatic drive, with three forward gears and a hydrostatic brake.
It has a 20 mph (32 km/h) maximum permitted travelling speed on plain line track
with an audible in-cab alarm if the maximum speed is exceeded. The machine is
also fitted with a passive speed restrictor which removes drive power when this
audible alarm sounds until the speed reduces. The machine is fitted with a data
logger, although this does not record the speed of the vehicle. At the time of the
accident, the machine was not fitted with a global positioning system (GPS) to
record its location or a closed-circuit television (CCTV) system.
Figure 3: Road‑rail vehicle used on 21 to 22 November (courtesy of Sonic Rail Services).
17 At the time of the accident, the RRV had no recorded defects. It subsequently
passed a static brake test in the hours following the accident and passed a
post- accident dynamic brake test on a later date (see paragraph 96). It was one
of two similar machines which had been in use on the Island Line for 5 weeks
preceding the accident as part of the major maintenance programme. The RRV
was being operated with an on‑track plant Engineering Conformance Certificate
issued in 2018 and valid for 7 years. This certificate was issued in accordance
with RIS-1530-PLT, ‘Rail Industry Standard for Technical Requirements of
On- Track Plant and Associated Equipment’, issue 6 dated December 2015, which
was in force when the certificate was issued.
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18 The hand trolley, which was struck by the RRV, weighs 50 kg unloaded and has a
The accident
carrying capacity of 1000 kg (figure 4). It had red lights affixed front and back as
required by GERT8000 (the Rule Book) HB10, ‘Duties of the COSS or SWL [safe
work leader] and person in charge when using a hand trolley’, issue 4.1, dated
November 2022.
19 Before the accident, the hand trolley was being used to carry hand-tools, jacks,
petrol-driven hand-tamping machines and fuel cans.
Figure 4: Hand trolley used on 21 to 22 November 2023.
Rail systems involved
20 The Island Line is a single-track railway, except for a 1.6 mile (2.5 km) section
of double-track between Ryde Esplanade and Smallbrook Junction. Passing
loops are provided at Brading and Sandown stations. The line is electrified via
a 750 V DC third rail system, controlled from Eastleigh electrical control room.
The line is signalled using colour light signalling which is controlled from Ryde St
Johns signal box.
21 The accident occurred on the Brading single line which has a permanent speed
limit for trains of 45 mph (72 km/h), reducing to 40 mph (65 km/h) just south of the
point of collision. In this area, the track is curved and constructed from flat-bottom
rail on timber sleepers (figure 5).
Staff involved
22 SWR employs a core team of seven infrastructure maintenance staff on the Island
Line. Most members of this team are trained to undertake ES and COSS duties
and had worked only, or mainly, on the Island Line infrastructure.
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The accident
Figure 5: Location of accident looking north. The RRV approached from this direction.
23 The safe work pack (SWP) for the track repair work on 21 to 22 November 2023
was prepared and signed by the SWR route section manager who had overall
responsibility for Island Line maintenance activities.
24 The ES for the work site had over 10 years’ experience on the Island Line.
They had taken over from a different ES part-way through the maintenance
programme.
25 The track repair work group was led by a COSS who had 4 years’ experience and
was also qualified as an ES, regularly undertaking these duties. The track repair
being undertaken comprised two tasks. These consisted of a group of two staff
measuring and identifying where track needed to be lifted, and another larger
group following in close proximity making the remedial repairs.
26 The track repair work group included a site supervisor, who had over 30 years’
experience on the mainland and on the Island Line as a track worker and
supervisor. The site supervisor had signed the SWP as the planner and was
working with another member of infrastructure maintenance staff to measure
the track geometry. Both were employed by SWR. The track repair work group
also included four experienced track workers, based on the mainland, and were
employed under contract by SGC.
27 The MO was employed by SRS and had over 10 years’ experience in operating
RRVs. The MC was also employed by SRS, was acting as COSS for the
RRV and had 4 years’ experience as a machine controller. Both had worked
within numerous possessions on infrastructure managed by Network Rail on
the mainland and had been working in possessions on the Island Line for the
previous 5 weeks. The MC and MO were in the RRV undertaking lineside
vegetation cutting during the possession. The MC travelled between sites of work
in the rear of the RRV’s cab which was provided for this purpose (figure 6).
Report 12/2024 14 October 2024
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The accident
Figure 6: RRV’s double cab. The MC sat in the rear part of the cab with limited forward visibility
(courtesy of Sonic Rail Services).
28 The MO is responsible for the RRV’s safe operation. The MC, with permission
from the ES, authorises safe movements of the RRV in a work site.
External circumstances
29 At the time of the accident, the weather was clear, cold (6°C) and damp with a
light wind. There was no external lighting.
30 SWR had issued warnings of expected poor rail adhesion conditions (red
adhesion status notices) covering their mainland network and the Island Line on
19 November and 20 November 2023. There was no equivalent warning issued
for 21 or 22 November as this was not warranted by the prevailing weather
conditions.
31 The accident occurred in a rural area with lineside trees and vegetation. There
are also areas on the railway between Ryde and Brading known to have a poor
mobile telephone signal.
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Background information
Background information
32 SWR holds a lease from Network Rail to operate, maintain and renew the Island
Line’s railway infrastructure. As a condition of its safety certificate, SWR is
required to comply with all relevant Network Rail and other standards applying
to the mainline railway on the mainland (such as Railway Group Standards).
However, these may be adapted to local circumstances on the Island Line if
supported by a risk assessment.
33 SWR adopted the use of GERT8000 for its activities on the Island Line
infrastructure. The possession on the night of the accident was set up in
accordance with Rule Book Module T3, ‘Possession of a running line for
engineering work’, issue 11 dated September 2022. Rule Book HB9, ‘IWA,
COSS or PC blocking a line’, issue 8 dated September 2022, states that a work
site is the portion of line within a possession of a running line where work will be
undertaken. Each work site is under the control of an ES. The ES is responsible
for authorising the entry of on-track plant (OTP) such as RRVs to the work site
and for any OTP movements within it.
34 A possession with an isolation of the electrical traction supply is taken on the
Island Line each Monday to Thursday night. Once the possession has been taken
by the PICOP, it is then handed over to the ES who manages it as a single work
site, extending the full length of the Island Line from the buffer stops at Ryde Pier
Head to the buffer stops at Shanklin. This differs from many possessions taken on
the mainland, which may be composed of several work sites.
35 Rule Book HB12, ‘Duties of the engineering supervisor (ES) or safe work leader
(SWL) in a possession’, issue 9 dated September 2022, requires work site marker
boards to be placed 100 m from each end of a work site. These are provided to
control the movement of on-track machines and OTP entering or leaving a work
site. These boards were not placed at the buffer stops during possessions on the
Island Line, as it was considered that there would be no purpose in doing so in
the circumstances.
36 Sites of work, each controlled by a COSS, are established within the work site.
The limits of sites of work were not required to be marked on site as part of the
agreed SWP.
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The sequence of events
The sequence of events
Events preceding the accident
37 During the week before the accident, the MC informed the ES that the RRV had
had trouble ascending the gradient where the accident later occurred due to
slippery rail conditions. On that occasion the RRV was towing a large trailer, and
the MO had found it necessary to increase the RRV’s speed at the bottom of the
slope to keep it moving all the way up. The ES did not take any action in response
to that report as there was no established process for doing so.
38 The ES arrived at Ryde St Johns depot at around 21:00 on Tuesday 21
November and was briefed by the site supervisor. The ES was informed that they
would be responsible for 3 sites of work within the work site during the overnight
possession, each with its own COSS. These consisted of the track repair work
group, a group working on Ryde Pier and another working between Brading
and Sandown. The ES was also responsible for two RRVs, one cutting back
vegetation along the railway and the other working in Sandown yard, each with
an MO and an MC also acting as a COSS. The ES did not make a written note of
the plan but believed that the track repair work group was going to start work at
Brading. The ES stated they briefed the COSSs for the three sites of work. The
ES told them not to go onto the track until the RRV had gone past, and that it
would be coming back during the possession.
39 The track repair work group assembled at Ryde St Johns depot before the
possession to be briefed by their COSS and to sign the safe work pack covering
the track repair task (referred to in this report as the SWP (track)). The SWP
(track) stated that the site of work for the work group would extend from 3 miles
33 chains to 4 miles 40 chains. Brading station is outside this area at 4 miles 55
chains (figure 9). The SWP (track) had been prepared by the section manager for
the repair of ‘level 2 twists’. This involved measuring the track and using jacks to
lift the track and repack the ballast to improve track geometry. The SWP (track)
identified that the site of work would be safeguarded, meaning that all lines would
be blocked to normal trains, and that engineering train or OTP movements would
be ‘made at no greater than 5 mph (10 km/h)’ in accordance with Rule Book HB9
(paragraph 33).
40 At around 22:00, the MC for the RRV involved in the accident attended Ryde
St Johns depot to sign in and receive a briefing from the ES, as they had done
before possessions during the previous 5 weeks. The MO was not required to
attend as their certificates had been checked previously by the ES. The MC (as
COSS) was responsible for briefing the MO when they arrived at Sandown yard,
where the RRV was stabled.
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41 The MO and MC were required to work in accordance with their own safe
The sequence of events
work pack (referred to in this report as the SWP (RRV)) which covered RRV
operations. This SWP (RRV) covered a series of possessions and had been
signed by the MC on 15 November 2023 and authorised by an SRS manager
the following day. A copy was signed again by the MC on 21 November 2023 to
cover the possession that night. The SWP (RRV) showed all lines as being under
possession with a speed limit of 5 mph (8 km/h), but the document was generic
and did not contain any information about other work groups present during
this possession. The MC then travelled to Sandown yard, where the RRV was
stabled, to meet and brief the MO.
42 At 23:50, the COSS received a phone call from the ES informing them that the
possession had been taken, but that the RRV would be passing through their site
of work in 10 to 15 minutes’ time. Members of the track repair work group were
loading equipment onto a vehicle at Ryde St Johns Road depot at this time.
43 The COSS and the track repair work group then travelled by road to a track
access gate at Rowborough Lane bridge (3 miles 60 chains) near the middle of
their planned site of work (figure 7). The COSS phoned the ES at 00:25 to confirm
they had arrived at the access gate, then briefed the work group that there would
be an RRV in the area.
Location of
accident
Figure 7: View from Rowborough Lane bridge looking north up the gradient towards location of
accident.
Report 12/2024 18 October 2024
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44 During the briefing at Sandown yard, the ES gave the MC a handwritten list of
The sequence of events
six locations where lineside vegetation was to be cut back (figure 8). As the SWP
(RRV) did not include details of any tasks or sites of work for the RRV, the ES
instructed the MC to start cutting vegetation at 1 mile 42 chains, towards the
north end of the line near Ryde St Johns station, and then travel back to the next
location at Rowborough Lane bridge (3 miles 60 chains). The MC stated that the
ES had told them that the track repair work group would be at Brading station.
The first two RRV sites of work were both located north of Brading (figure 9).
Shanklin
Brading
Rowborough Lane
bridge and access
Ryde St Johns
Figure 8: Handwritten list of sites of work which the ES gave to the MC.
45 At about 00:30 on Wednesday 22 November, the MO and MC travelled north in
the RRV. After passing Brading station, they encountered members of the track
repair work group by the track near the Rowborough Lane bridge access point.
They stopped the RRV and waited until members of the work group were in a
position of safety before passing them. The MO and MC acknowledged the work
group and the RRV continued its journey.
46 As the RRV ascended the gradient in the area where the accident later occurred,
the MO stated they heard a “crunching noise”. Although the wheels did not
slip, they mentioned this to the MC. The MO believed the noise was caused by
leaf mulch on the railhead. This was the first occasion within the maintenance
programme where the RRV had climbed the gradient without towing a trailer.
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The sequence of events
Ryde Pier Head
N
Ryde Esplanade
Ryde St Johns Road
depot
1 mile (0.6 km)
Smallbrook Junction
3 m 33 ch
Accident location
Rowborough Lane
access gate (3 m 60 ch) 4 m 40 ch
Brading (4 m 55 ch)
Sandown
Sandown yard RRV sites of work (x6)
Track repair work group site of work
Lake
Other sites of work
Milepost
Station
Shanklin
Figure 9: Sites of work on 21 to 22 November.
47 After the RRV had passed the work group, the trolley was put onto the line by
members of the work group and loaded with equipment. The work group then
pushed it north up the gradient, following the direction of travel of the RRV. They
stopped at around 3 miles 37 chains, 463 metres from the access point.
48 The work group started to measure and correct track faults. The work was
undertaken using head torches which were considered adequate for this task.
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Brading
49 Aware that the RRV would need to pass again at some point on its return journey,
The sequence of events
the COSS did not participate directly in the track repair work and they were
anticipating a phone call from the ES notifying them that the RRV was travelling
back towards their site of work. The COSS believed that the RRV would not
approach the site of work without them receiving a call from the ES.
50 After completing vegetation trimming at the RRV’s first site of work near Ryde
St Johns, it started its return journey travelling south towards its second site of
work next to Rowborough Lane bridge (figure 9). This required the RRV to pass
through the track repair work group’s site of work.
51 From Ryde St Johns, the line south climbs towards a summit at 3 miles 20 chains.
The MO was aware of the incline and stated that they drove slightly faster than
5 mph (8 km/h) in second gear which allows a maximum speed of 15 mph
(24 km/h) to make it up the incline. Although it was not discussed, both the ES
and the MC believed that the RRV already had approval from the ES to travel
at more than 5 mph (8 km/h) within the work site while moving to, or between,
its sites of work as it had been doing so earlier in the major maintenance
programme. An ES may permit movements at a speed above 5 mph (10 km/h)
under certain conditions (see paragraph 71).
Events during the accident
52 Members of the track repair work group were correcting a track fault at 3 miles
37 chains when the COSS noticed a bright light approaching from the north. The
COSS had not been contacted by the ES about the RRV’s return journey, but
recognised the lights as being those on the RRV. The COSS instructed the work
group to remove all tools and the trolley from the track and move to a position of
safety.
53 The RRV, on passing over the summit of the hill, started to descend. Analysis
undertaken by RAIB has concluded that the MO would have been able to see the
work group from the RRV cab from a maximum of 240 metres away, as sighting
was obstructed by trees on the inside of the left-hand curve before this point
(figure 10). As they came into view, the MO could see the reflective strips on the
work group’s protective clothing. The usual procedure when the RRV encountered
work groups on the track during possessions was to stop close enough to the
work group to allow the MC and COSS to communicate and arrange the safe
passage of the RRV. The MO anticipated, therefore, that they would need to stop
and wait until the track was clear and they could be waved through.
54 As the RRV approached the work group, witness evidence indicates that the MO
lifted their foot off the RRV’s accelerator pedal intending to slow the vehicle down
using the hydrostatic drive. The MO stated that they had never had a reason
to brake going down this gradient before. Instead of the vehicle quickly slowing
down as expected, the MO could see that the front rail wheels had stopped
rotating and, along with the MC, could feel that the RRV was sliding. Both the MO
and MC stated that they had not experienced this before.
Report 12/2024 21 October 2024
Brading
The sequence of events
Track repair
work group’s
location
Figure 10: View looking south from 3 miles 25 chains, with first sighting of the accident location around
240m ahead.
55 The MO applied the brake which had no effect because the wheels were sliding.
They tried briefly accelerating to restore grip to then stop the vehicle. The MO
realised the RRV was not stopping and sounded the horn. The MO and MC both
opened their cab doors and shouted warnings for the work group to clear the
track.
56 Members of the track repair work group heard the horn and shouting from the
cab and realised that the RRV was not able to stop. One witness reported that
it appeared to increase in speed as it approached. Members of the work group
quickly moved the tools and equipment off the trolley. Two members of the work
group then lifted the trolley and threw it into the cess beside the track, where it
landed at an angle and, unknown to the work group, it remained foul of the RRV’s
path.
57 All members of the work group were clear of the track as the RRV approached
them. Witness accounts of the RRV’s speed vary widely. Its likely speed is
discussed further at paragraph 93. As the RRV passed, its front right rubber tyre,
which extended beyond the rail (figure 11), clipped the corner of the trolley. The
trolley spun round and struck two members of the work group.
58 The site supervisor and another member of the work group were measuring the
track beyond the point of collision. They were not affected because they had
heard the RRV’s horn and the shouting and had moved to a position of safety.
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The sequence of events
Figure 11: An RRV of the same type showing the overhang of the rubber tyre in relation to the rail
(courtesy of Sonic Rail Services).
59 The MO and MC believed the group and trolley were clear of the track when they
started to pass them. The MO and MC were unaware that the RRV’s tyre had
struck the corner of the trolley as they did not feel the impact. They were also
unable to see the collision due to the view from the RRV’s cab being obstructed
by part of the machine.
60 After the RRV came to a stop, the MC got out via the rear cab door to check the
RRV wheels for a possible cause of the RRV’s poor stopping performance. They
did not find anything of concern.
Events following the accident
61 After the accident, the COSS went to the RRV and informed the MC that a
collision had occurred. The RRV moved back towards the work group to shine its
lights onto the area (figure 12). The MO and MC observed that all members of the
work group were standing up and stated that they were not informed that there
had been any injuries.
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The sequence of events
Figure 12: Location of accident looking south.
62 The ES had earlier been contacted by the work group on Ryde Pier and asked
to pick up some track clips from Ryde St Johns depot and deliver them to Ryde
Esplanade. They were fulfilling this task when the site supervisor phoned them
and stated there had been an incident.
63 The COSS phoned the ES at 01:54 and reported the accident straight after the
RRV hit the trolley. They also checked on the welfare of those who had been
struck. The COSS decided that the track repair work group should stop work and
return to the access point at Rowborough Lane bridge. The group subsequently
returned to Ryde St Johns depot for welfare checks.
64 Although the ES had been informed of the circumstances of the accident, they
were unaware of its severity and did not implement procedures to obtain or
protect evidence. The RRV was allowed to carry on working, and subsequently
moved to the next planned site of work close to Rowborough Lane bridge and
started cutting vegetation. Work was stopped when the ES contacted the MC a
short time later, having become aware of the full extent of the accident.
65 The accident was not reported internally promptly in accordance with SWR
procedures, and RAIB was not notified until more than 12 hours after the
accident. In addition to this late reporting, critical evidence from the accident was
not preserved by SWR. These issues are discussed further in paragraph 111.
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Analysis
Identification of the immediate cause
66 The track repair work group was given insufficient warning to be able to
safely remove the trolley from the track when the RRV approached.
Identification of causal factors
67 The accident occurred due to a combination of the following causal factors:
a. The COSS of the track repair work group had not been informed of the RRV’s
movement before it approached (paragraph 68).
b. The RRV was unable to stop in the expected distance once the MO realised
the track repair work group was ahead (paragraph 81).
These factors are now considered in turn.
Communication between ES and COSS
68 The COSS of the track repair work group had not been informed of the
RRV’s movement before it approached.
69 This causal factor arose due to a combination of the following:
a. The ES was unaware that there was an RRV movement that created a
potential risk to the track repair work group and so did not warn the COSS
(paragraph 70).
b. The safe system of work adopted by the work group relied on the ES warning
the COSS of any RRV movements (paragraph 76).
Each of these factors is now considered in turn.
ES’s risk awareness
70 The ES was unaware that there was an RRV movement that created a
potential risk to the track repair work group and so did not warn the COSS.
71 Rule Book HB12 states that only the ES can authorise a train movement to enter,
or be made within, a work site. It also states the ES has to agree the safe system
of work with each COSS, recording these details on their RT3199 ‘Work- site
certificate’. HB12 also permits an ES to allow machine movements to run at
caution (that is, be able to stop within the distance the operator can see above
5 mph (10 km/h)). But this is conditional on the ES giving specific instructions
to the MC, and dependent on any agreement made with COSSs. No specific
agreement was made with the COSSs during this possession.
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72 Clause 7.1 of Rule Book HB15, ‘Duties of the machine controller (MC) and
Analysis
on‑track plant operator’, issue 6 dated September 2022, states that OTP
movements can only enter or take place within a work site when the ES gives
permission. The ES stated however that they would not have required the MC to
seek their authorisation to move the RRV between its sites of work if there were
no other work groups on the track in those areas. In this possession, unlike in
some possessions during the preceding 5 weeks, there was a work group moving
within a site of work extending between 3 miles 33 chains and 4 miles 40 chains
(paragraph 39). However, as the ES believed the track repair work group would
be at Brading (4 miles 55 chains), they did not consider that there was a risk of a
conflicting move due to the RRV having to pass the work group a second time.
73 No details of the position of the track repair work group were provided to the MC
in the SWP (RRV), with this and the SWP (track) being separate documents,
each covering covering several possessions and with limited cross-referencing
(paragraphs 39 and 41).
74 The MC stated that their understanding from the pre-work briefing provided by
the ES was that this gave them the necessary authorisation for movements
between the sites of work listed, negating any requirement for the MC to call
the ES before any RRV movements. This arrangement had been applied during
previous possessions and the MC stated they would only expect to call the ES in
exceptional circumstances, for example, if points needed to be moved. On this
basis, the MC did not attempt to contact the ES before permitting the MO to move
the RRV from its first site of work near Ryde to its second site of work located
near the access point at Rowborough Lane bridge.
75 Despite having knowledge of the track repair work group’s earlier location, from
having previously passed them, the MC and MO believed that the work group
would be moving south towards Brading. They were unaware that the RRV’s
second site of work was also within the track repair work group’s site of work,
so they were not expecting to need to stop. This meant that the presence of the
work group ahead of the RRV was unexpected, reducing the time and distance
available to the MC and MO to react to it.
Safe system of work
76 The safe system of work adopted by the work group relied on the ES
warning the COSS of the RRV movements.
77 For a COSS to treat their safe system of work as safeguarded, Rule Book HB9
requires them to establish with the ES that either there will be no OTP movements
at their site of work, or that any movements will be made at no greater than 5 mph
(10 km/h). The COSS is also required to ensure that they and their group are in a
safe position before any OTP passes through their site of work.
78 The list of sites where the RRV was due to work included two locations north of
Brading. These required the RRV to pass the work group’s location twice and the
COSS was aware of this.
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79 At the start of the possession, the ES instructed the COSS to wait until the RRV
Analysis
had passed on its outbound journey before going onto the track. The COSS
stated that they were expecting the ES to call and warn them for any movements
where the RRV was going to pass their work group. This understanding
essentially reflects the requirements of Rule Book HB12 and HB15 that the ES
authorises each OTP movement within a work site, and of HB9 which requires the
COSS to establish if there are any OTP movements which could affect their group
when working under a safeguarded system of work.
80 The COSS and ES worked together frequently but it is not clear if this specific
issue had ever been recognised as a risk or if it had been briefed or discussed.
In this case, the lack of a clear understanding about the process to be followed
for OTP movements meant that these movements were not being specifically
authorised by the ES, and that the COSS was not being warned about potentially
conflicting moves with their group.
RRV braking
81 The RRV was unable to stop in the expected distance once the MO realised
the track repair work group was ahead.
82 The MO and MC travelled in the RRV between sites of work. The MO drove
using the line-of-sight principle, meaning they would stop the RRV and wait if
they saw an obstruction or people on the line ahead. The speed would be low but
not necessarily below 5 mph (8 km/h). Because they were working line-of-sight,
the risk of an accident occurring at the location where the track repair group was
working was increased as it was on a curve with restricted visibility. The risk was
also increased due to the relatively steep descending gradient at the site, which
would extend braking distances. Both SWPs indicated that there was a gradient
of 1 in 78 where the accident occurred and identified the risk of RRV runaways on
a gradient steeper than 1 in 100.
83 This causal factor arose due to a combination of the following:
a. Low wheel/rail adhesion at the location was almost certainly created by
environmental conditions on the night (paragraph 84).
b. The MO and MC were not aware that there was a risk of low adhesion
conditions affecting the braking of the RRV to the degree that it did
(paragraph 91).
These factors are now considered in turn.
Low adhesion conditions
84 Low wheel/rail adhesion at the location was almost certainly created by
environmental conditions on the night.
85 On the return journey, as the RRV approached the work group and the MO took
their foot off the RRV’s accelerator pedal to slow it down, its rail wheels locked
and began to slide (paragraph 54).
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86 Wheel/rail adhesion conditions at the time of the accident are not known as no
Analysis
rail or wheel contamination samples were taken after the accident occurred (see
paragraph 112). Weather conditions were cold and damp (paragraph 29) which
was typical of an autumn night. It is likely that the relative humidity of the air was
high, causing dew to collect on the rails. It is also possible that contamination of
the RRV’s rail wheels occurred during the earlier vegetation flailing activity and
that this also affected the available wheel/rail adhesion.
87 The accident occurred during the autumn leaf-fall period and although no
adhesion status notices were applied at the time of the possession, Network Rail
and SWR had issued a red alert warning for poor railhead conditions for the two
days before the accident (paragraph 30).
88 Although the MO and MC had never previously had any difficulty in stopping the
RRV, they reported they had had trouble getting the RRV to climb the gradient
at the location where the accident occurred during a possession the previous
week (paragraph 37). Photographs taken the day before the accident by the
section manager as part of an unrelated site inspection show no obvious railhead
contamination (figure 13). However, guidance published by the Rail Delivery
Group ‘Managing low adhesion – seventh edition (May 2024)’ states that the
adhesion profile along any stretch of line can vary within metres, and temperature
and humidity levels can also change rapidly. As such, adhesion levels can vary
rapidly in terms of both time and location.
Figure 13: Railhead condition near the site of the
accident on 21 November. Image also shows
a chainage marker plate provided at regular
intervals along the Island Line (courtesy of South
Western Railway).
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89 There are no signals in this area and train drivers would not normally be required
Analysis
to apply their brakes approaching the location of the accident site. Any possible
low adhesion conditions at this location would therefore possibly not be apparent
to a train driver unless wheel slip occurred ascending the gradient. Documentary
evidence supports this as there was no evidence of train drivers making reports of
low adhesion (ROLA) on the Island Line in the period before the accident.
90 The Island Line has no recorded history of problems with low wheel/rail adhesion
and its infrastructure team was not routinely informed of low adhesion conditions
by SWR. This resulted in the Island Line having no effective low adhesion
management process (see paragraph 102).
Risk awareness
91 The MO and MC were not aware that there was a risk of low adhesion
conditions affecting the braking of the RRV to the degree that it did.
92 The MO was aware that there may have been leaf mulch on the railhead near the
accident location on the RRV’s outbound journey (paragraph 46). However, the
RRV did not experience any slipping, and the MO and MC did not perceive any
increased risk of poor adhesion.
RRV braking performance
93 The speed of the RRV as it approached the track repair work group is unknown,
but witness evidence was that the RRV was in second gear, so it was probably
travelling at between 5 mph (8 km/h) and 15 mph (24 km/h). The MO and MC
believed they had the ES’s agreement to exceed 5 mph (8 km/h) (paragraph 51).
94 The relevant Rail Industry Standard for OTP, RIS-1530-PLT, ‘On-Track Plant,
Trolleys and Associated Equipment’, issue 6 dated December 2015, states that
a powered machine shall be capable of stopping a fully laden machine on level
track and in dry and uncontaminated conditions in the following distances:
• 5 mph: stopping within 6 metres
• 10 mph: stopping within 18 metres
• 15 mph: stopping within 36 metres.
95 In the absence of evidence of the actual speed of the RRV, the exact location
where the MO first attempted to slow the vehicle, or the prevailing level of
wheel / rail adhesion, it is not possible to accurately estimate the braking
performance of the vehicle on the 1 in 78 falling gradient on which the RRV was
approaching the group. However, witness evidence shows that the location where
the MO first attempted to slow the RRV was sufficiently far from the work group
to allow the work group time to react, clear the trolley and lift it off the track before
the RRV passed (paragraph 54). The RRV eventually stopped around 100 metres
beyond the point of collision (paragraph 8).
96 A wheelset inspection, wheel torque test and static brake test were undertaken
on the RRV later that same day and did not identify any immediate defect with the
RRV’s wheels or braking system. It passed dynamic brake testing requirements
for OTP set out in RIS-1530-PLT, although this testing was not undertaken until
late January 2024, 10 weeks after the accident. In the test, the RRV was able to
stop well within the distances required by RIS-1530-PLT. Brake tests were also
performed at 10 mph (16 km/h), which showed that the RRV was able to stop
within the allowable limit as per RIS-1530-PLT.
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97 This suggests that the normal stopping distance of the RRV was increased to a
Analysis
significant degree, by low wheel/rail adhesion and the effect of the gradient.
Identification of underlying factors
Possession planning
98 SWR’s process for planning and managing possessions did not effectively
manage the risk of OTP movements and the risk of OTP and trolley
collisions.
99 Before the accident, the process used on the Island Line for planning possessions
did not include a pre-possession review meeting to identify and deconflict works
within the possession. There was also no recognised method to manage OTP
movements.
100 This lack of a pre-planning meeting meant that those responsible for the planning
and delivery of the work potentially missed an opportunity to consider the RRV’s
movements through other sites of work within the work site and to consider how
these could be safely managed.
101 The lack of co-ordinated planning also meant that the track repair work group
and the RRV personnel were using different safe work packs with minimal
cross‑referencing between them, resulting in a limited shared awareness of
potential conflicts. For example, while the SWP (track) identified the risk from
RRV movements and the gradient, effective control measures were not identified.
The SWP (RRV) gave no information on the location of the track repair work
group during the possession because it was a generic document covering
multiple possessions.
Management of low adhesion risk
102 SWR had no effective process for managing low wheel/rail adhesion risk for
maintenance work on the Island Line.
103 SWR operations manual IL-AP23 ‘Autumn leaf fall arrangements’, dated August
2023, was marked as applicable to engineering and infrastructure as well as train
service delivery. Despite this, it only contained instructions for the safe operation
of service trains. It covered the period from 1 October to 13 December 2023 and
was to be accompanied by briefings for train drivers and guards. A report of low
adhesion would require the site to be inspected and cleaned if necessary. There
were no high-risk sites listed for low adhesion on the Island Line.
104 The arrangements in this document were that low adhesion was to be managed
by the on-call duty manager making spot checks and following up on driver
reports. However, SWR believed that the Island Line was not affected by
problems with low adhesion as the reporting system used by train drivers had not
resulted in any reports being received. This may have been because train speeds
on the line are relatively low, and it would be unusual for a train to need to stop
between signals or stations.
105 The Island Line infrastructure maintenance team had hand scrubbers to remove
leaf debris from the railhead, but no jetting equipment. There was no proactive
cleaning programme, and the scrubbers had never been used before the
accident, due to the lack of reports about low adhesion.
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106 The autumn adhesion management process that is routinely used on the
Analysis
mainland by Network Rail and train operators was not applied to the Island Line.
This was because SWR had no previous reports of low adhesion and did not
believe that it was an issue on the Island Line. It may also be because SWR is
primarily a train operating company, and so did not have a good awareness of low
adhesion risk for OTP operating on the Island Line.
Possession assurance
107 SWR’s assurance of possession management on the Island Line did not
identify the extent of informal working practices present.
108 RAIB’s investigation found that maintenance activities on the Island Line did
not always comply with the requirements of the Rule Book modules relating to
possession activities. For example, the ES did not correctly observe the rules
for controlling RRV movements (paragraph 72). RAIB also found that the ES
did not have a written record of the track repair work group’s location or the
limits of their site of work even though these should have been recorded by
them on form RT3199, along with the safe system of work being used by each
COSS (paragraph 71). Rule Book HB9 states that the ES must enter the agreed
details on form RT3199 and get the COSS to sign it. This is to confirm shared
understanding and agreement of the arrangements in place.
109 Informal work practices may have developed due to the isolated nature of the
Island Line and because the work was organised and implemented by small
teams who were familiar with working together.
110 The fact that processes were not always being applied correctly and that some
informal work practices existed was not detected or corrected by SWR. This was
because SWR did not undertake any assurance activities on how Island Line
maintenance activities complied with the requirements of the Rule Book modules
relating to possession activities.
Observations
Post-accident actions
111 The actions taken in response to the accident led to a loss of evidence and
did not follow industry standards or legal requirements.
112 Following the collision, the COSS initially responded by ensuring the welfare of
the work group. The site supervisor and the COSS both notified the ES of the
accident by phone. Although now aware of the accident, the ES was unaware
of its severity and did not take the lead or provide guidance to the COSS in
identifying or protecting evidence. This meant that critical locations at the accident
site were not marked or photographed, and the railhead was not examined for
possible contamination. The requirement for drugs and alcohol testing for the staff
involved was not considered until after some of them had left site.
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113 The site supervisor took the lead in reporting the accident. After returning to
Analysis
Ryde St Johns depot, they rang the signaller to obtain details for the Island Line’s
on-call manager. The signaller advised this information should be found in the
published weekly operating notice (WON). The site supervisor contacted the
Island Line’s on-call manager at 03:45 (the collision occurred approximately at
01:50) and informed them that a near miss had occurred and that no one was
injured. At that point no member of the work group had reported an injury. The
on- call manager requested drugs and alcohol testing but was told that the staff
had left site.
114 The site supervisor was unaware that SWR’s reporting arrangements had
changed in 2020 to match arrangements on the mainland. Although the WON
instructed that the on-call manager was to be contacted first, SWR required
incidents to be reported to the SWR duty control manager first. The on-call
manager reported the incident to SWR’s duty control manager at around 10:30,
the delay being attributed to the on-call manager managing the aftermath of an
unrelated break-in at Ryde St Johns station. The on-call manager also assumed
that the site supervisor had already reported the incident to the duty control
manager.
115 Island Line infrastructure maintenance staff and contractors were not familiar
with the M&EE Networking Group industry codes of practice for OTP, specifically
COP0019, ‘Code of Practice for action to be taken in the event of an accident
or incident involving OTP’, issue 6 dated March 2022, which includes the
requirement to arrange post-incident dynamic brake testing. This meant that
the dynamic brake test of the RRV was not undertaken until 10 weeks after the
accident, in January 2024.
116 RAIB was not notified of the accident for more than 12 hours. The initial
notification stated that an RRV had slid and struck a works trolley, but that neither
vehicle had derailed, no injuries had occurred and that there was no damage.
Further enquiries revealed that people had been struck in the accident.
117 Regulation 4 and Schedule 1 of the Railways (Accident Investigation and
Reporting) Regulations 2005 (as amended) require that accidents and incidents,
that in slightly difference circumstances could have led to serious injury or worse,
should be immediately notified to RAIB. RAIB would, therefore, expect the type of
accident seen at Brading to have been notified immediately. RAIB’s guide about
notifying accidents states that if there is any doubt about whether an accident is
notifiable to RAIB, then duty holders such as SWR should notify anyway.
118 Regulation 7 of the 2005 Regulations also requires duty holders to preserve
evidence relating to accidents and incidents for examination by RAIB. Failing to
preserve evidence can hamper safety investigations and reduce the opportunities
to learn important lessons from accidents and incidents.
Gradient information
119 Gradient reference information was inaccurate.
120 Gradient information available to SWR and SRS was not accurate in the area
where the accident occurred. RAIB’s post-accident measurements at the site
indicate that the start of the gradient on which the accident occurred is around
300 metres north of the location stated in reference data held by Network Rail and
used to prepare the SWPs.
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121 Further discrepancies were identified in SWR document ‘601 complete map’
Analysis
which shows the track as level at the accident location, and a historical ‘5-mile
line diagram’ which shows the gradient as 1 in 300. The inaccuracy and disparity
in these sources of information may reduce SWR’s ability to plan work safely,
particularly where vehicles and trolleys are involved.
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Summary of conclusions
Summary of conclusions
Immediate cause
122 The track repair work group was given insufficient warning to be able to safely
remove the trolley from the track when the RRV approached (paragraph 66).
Causal factors
123 The causal factors were:
a. The COSS of the track repair work group had not been informed of the RRV’s
movement before it approached (paragraph 68). This causal factor arose due
to a combination of the following:
i. The ES was unaware that there was an RRV movement that created a
potential risk to the track repair work group and so did not warn the COSS
(paragraph 70, Recommendation 1).
ii. The safe system of work adopted by the work group relied on the
ES warning the COSS of any RRV movements (paragraph 76,
Recommendation 2).
b. The RRV was unable to stop in the expected distance once the MO realised
the track repair work group was ahead (paragraph 81). This causal factor
arose due to a combination of the following:
i. Low wheel/rail adhesion at the location was almost certainly created by
environmental conditions on the night (paragraph 84).
ii. The MO and MC were not aware that there was a risk of low adhesion
conditions affecting the braking of the RRV to the degree that it did
(paragraph 91).
Underlying factors
124 The underlying factors were:
a. SWR’s process for planning and managing possessions did not effectively
manage the risk of OTP movements and the risk of OTP and trolley collisions
(paragraph 98, Recommendation 1)
b. SWR had no effective process for managing low wheel/rail adhesion risk for
maintenance work on the Island Line (paragraph 102, Recommendation 1)
c. SWR’s assurance of possession management on the Island Line did not
identify the extent of informal working practices present (paragraph 107,
Recommendation 2).
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Additional observations
Summary of conclusions
125 Although not linked to the accident on 22 November 2023, RAIB observes that:
a. The actions taken in response to the accident led to a loss of evidence and did
not follow industry standards or legal requirements (paragraph 111, Learning
points 1, 2 and 3).
b. Gradient reference information was inaccurate (paragraph 119,
Recommendation 3).
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Actions reported as already taken or in progress relevant to
Actions reported as already taken or in progress relevant to this report
this report
Actions reported that address factors which otherwise would have
resulted in an RAIB recommendation
126 SWR has reported that it has:
a. introduced a formal planning meeting for maintenance activities including
the use of whiteboards during pre-possession planning showing the relative
location of works and the works phase which has improved the management
of possessions
b. introduced an ES briefing form which is handed to the COSS in addition to
the verbal briefing and requirement for the COSS to sign the RT3199 form to
confirm their understanding
c. provided a briefing to Island Line infrastructure maintenance staff on
post‑incident actions and the requirement to preserve evidence
d. undertaken a new risk assessment for machine movements
e. issued a briefing to all infrastructure staff on machine movements
f. reviewed its post-incident response for Island Line incidents which has
included establishing competency requirements
g. taken steps to address the deficiencies found within its assurance processes
for monitoring compliance with the requirements of the Rule Book modules
relating to possession activities.
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Recommendations and learning points
Recommendations and learning points
Recommendations
127 The following recommendations are made:1
1 The intent of this recommendation is for South Western Railway to
review how it manages safety during infrastructure work on the Island
Line.
South Western Railway should undertake a risk-based review of its
arrangements for:
a) planning and management arrangements for possessions, work sites
and sites of work
b) the movement of on-track plant, including risks relating to gradients
and low wheel/rail adhesion.
This should include the applicability of the provisions of GERT8000 (the
Rule Book) for managing Island Line infrastructure works.
Following this review, South Western Railway should develop a
timebound plan to make any appropriate changes identified to standards,
processes and its organisational structure (paragraphs 123.a.i, 124.a,
124.b).
2 The intent of this recommendation is for South Western Railway to
review its assurance processes.
South Western Railway should review assurance processes to
understand if they are effective at detecting informal, non-compliant and
unsafe practices during infrastructure work on the Island Line.
Following this review, South Western Railway should develop a
timebound plan to make any appropriate changes identified to standards,
processes and its organisational structure (paragraphs 123.a.ii, 124.c).
1
Those identified in the recommendations have a general and ongoing obligation to comply with health and safety
legislation and need to take these recommendations into account in ensuring the safety of their employees and
others.
Additionally, for the purposes of regulation 12(1) of the Railways (Accident Investigation and Reporting) Regulations
2005, these recommendations are addressed to the Office of Rail and Road to enable it to carry out its duties
under regulation 12(2) to:
(a) ensure that recommendations are duly considered and where appropriate acted upon; and
(b) report back to RAIB details of any implementation measures, or the reasons why no implementation measures
are being taken.
Copies of both the regulations and the accompanying guidance notes (paragraphs 200 to 203) can be found on
RAIB’s website www.gov.uk/raib.
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Recommendations and learning points
3 The intent of this recommendation is for South Western Railway to
provide its infrastructure maintenance staff and contractors with accurate
information about its infrastructure.
South Western Railway should establish the accuracy and completeness
of gradient information used for planning possession works on its
infrastructure so that the risks associated with runaways and low
adhesion can be understood and managed. The revised information
should be provided to Network Rail Technical Authority to enable industry
reference information to be updated (paragraph 125.b).
Learning points
128 RAIB has identified the following important learning points:2
1 Transport undertakings and on-track plant operators are reminded
of the importance of applying industry codes of practice in the event
of an accident or incident involving on-track plant. This includes
COP0019 ‘Code of Practice for action to be taken in the event of an
accident or incident involving OTP’, published by the Rail Safety and
Standards Board (RSSB) on behalf of the M&EE Networking group
(paragraph 125a).
2 Duty holders are reminded to promptly report serious and potentially
serious accidents to RAIB in accordance with the Railways (Accident
Investigation and Reporting) Regulations 2005 (as amended). Failing to
do so can result in evidence loss and reduced opportunities for safety
learning (paragraph 125a).
3 Duty holders are reminded of the importance of having well-established
processes and procedures for dealing with post-accident evidence
collection and testing (paragraph 125a).
2
‘Learning points’ are intended to disseminate safety learning that is not covered by a recommendation. They are
included in a report when RAIB wishes to reinforce the importance of compliance with existing safety arrangements
(where RAIB has not identified management issues that justify a recommendation) and the consequences of failing
to do so. They also record good practice and actions already taken by industry bodies that may have a wider
application.
Report 12/2024 38 October 2024
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Appendices
Appendices
Appendix A - Glossary of abbreviations and acronyms
Abbreviation / acronym Full term
CCTV Closed-circuit television
COSS Controller of site safety
ES Engineering supervisor
MC Machine controller
MO Machine operator
OTP On-track plant
PICOP Person in charge of possession
RRV Road-rail vehicle
RSSB Rail Safety and Standards Board
SGC SGC Rail Solutions
SRS Sonic Rail Services
SWL Safe work leader
SWP Safe work pack
SWR South Western Railway
WON Weekly operating notice
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Appendix B - Investigation details
Appendices
RAIB used the following sources of evidence in this investigation:
• information provided by witnesses
• safe work packs
• RRV test reports and certificates
• RSSB industry guidance including rule book handbooks
• site photographs and gradient measurements
• gradient reference information
• weather reports and observations at the site
• SWR red alerts and seasonal briefings
• SWR standards and procedures
• a review of previous RAIB investigations that had relevance to this accident.
Report 12/2024 40 October 2024
Brading
This report is published by the Rail Accident Investigation Branch,
Department for Transport.
© Crown copyright 2024
Any enquiries about this publication should be sent to:
RAIB Email: enquiries@raib.gov.uk
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Derby UK
DE21 4BA