At approximately 03:00 hrs on 10 September 2011, a hand trolley ran unattended for a distance of 2.9 miles (4.6 km) along the Portsmouth main line near Haslemere. The incident occurred within an overnight engineering possession and there were no casualties.
The trolley operator did not know he was on a long falling gradient when he let go of the trolley and the brakes on the trolley failed to apply automatically. The brake mechanism probably jammed with the brakes in the ‘off’ position due to a combination of factors including inadequacies in the design, risk assessment and acceptance processes, and in the subsequent maintenance of the trolley.
RAIB has made five recommendations to Network Rail. These relate to the training and competence of trolley operators, the product acceptance process, reviewing the actions it has taken since the incident, alternative means of communication in areas of poor mobile phone reception and the process for reviewing RAIB recommendations made to other operators. One recommendation is made to Torrent Trackside, the maintainer of the trolley, to improve the competence of its staff to maintain equipment.
As a learning point from this incident, RAIB has also identified that duty holders should have effective processes for making sure their staff are made aware of changes in the Rule Book which are relevant to the work they perform.
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.
Published 10 December 2014