Shared Learning – NRL21-03 On track plant collision
OVERVIEW
On the 2nd May 2021 at 07:00, the Machine Operator of a Mobile Elevating Work Platform (MEWP) Road Rail Vehicle (RRV) suffered life changing injuries when the basket of the MEWP in which they were travelling was struck by the jib of a 360º Crane RRV which had been travelling behind it.
The collision occurred whilst both vehicles were travelling to their off-tracking location on the same line within an engineering worksite.
The MEWP Machine Operator was trapped and had to be freed by the emergency services.
The MEWP Machine Controller sustained minor bruising.
Both the Machine Operator and Machine Controller who were travelling in the cab of the 360º Crane RRV were uninjured.
UNDERLYING CAUSES
- Planning focussed on the work activities, and not on the travelling.
- Only 30 minutes travel time between worksites had been planned, however this would have taken one hour at walking pace with the Machine Controller on the ground, and not on the On Track Plant (OTP).
- The OTP plan made no reference to speed limits or required distances between machines when travelling.
- The 100 metre minimum separation distance between machines was not achieved when the RRVs were travelling in convoy throughout the shift.
- Machine Controllers were riding in machines throughout the shift.
- The MEWP basket should have been travelling in the leading position but was in the reversing position (within the crush zone).
- The quality of the briefings were inconsistent due to the generic nature of the documentation.
- None of those involved had received a project induction from the Principal Contractor.
- Responsibilities were unclear due to a number of contradictory and confusing instructions contained within the Rule Book and Network Rail Standards (Infrastructure Plant Manual NR/L2/RMVP/0200 and POS Rep guidance).
- Despite rule breaking taking place, no one onsite took the opportunity to speak up for safety or invoke the worksafe procedure.
- Learning and findings from similar incidents had not been shared across the wider industry and had not been fully actioned or embedded within all the organisations involved.
KEY MESSAGE
- Machine Controllers should not ride in the plant except where permitted through planning and documented in the OTP plan.
- Whilst travelling in convoy, OTP must maintain 100 metres minimum separation between plant unless alternative acceptable controls are in place and fully documented in the OTP plan.
- Teams and individuals should be encouraged to speak up for safety and raise close calls where rules are not being complied with.
- Documentation should be specific to the works being undertaken.
- Planners should consider all aspects of the work to be undertaken, not just on the work activities.
- POS Planners preparing OTP plans should be fully engaged in the planning process.
- Principal Contractors must make sure there is clarity on roles and responsibilities relating to OTP movements.
- Organisations should make sure that robust investigations are undertaken and that learning is shared within the industry using the existing mechanisms. E.g. the Operational Safety Notices portal.
