On Wednesday 19 July 2006 a volunteer train guard on the Gwili Railway became trapped between two carriages as they were being coupled together during a shunting manoeuvre at Bronwydd Arms station. He died from his injuries in hospital later that day.
The immediate causes of the accident were a misunderstanding of shunting hand signals, resulting in the driver moving a carriage to couple up to others that were stationary, and at the same time the guard stepping into the gap between the carriages in the belief that the vehicles would not move. There were four contributory factors to the accident. The underlying causes were the practice of volunteers multi-tasking in safety-critical activities, and on this occasion without clear understanding of their limits, and the safety management organisation and its application at the railway.
The RAIB has made nine recommendations aimed at:
- shunting procedures
- the management of safety related documents and records
- the competence and medical standards for staff
- compliance with safety procedures and standards
Response to recommendations:
- RAIB will periodically update the status of recommendations as reported to us by the relevant safety authority or public body.
- RAIB may add comment, particularly if we have concerns regarding these responses.