The Rail Accident Investigation Branch has released a safety digest after a Pacer train ran away at Dereham on the Mid Norfolk Railway.
On December 10 2020 at around 15:52, the Pacer train narrowly avoided hitting pedestrians and road vehicles after it became detached from the low loader winch at Dereham Station.
The RAIB says that the level crossing was open to road users and no arrangements were in place to prevent a runaway carriage from reaching the level crossing.
The low loader driver and escort van driver worked together whilst unloading. The low loader driver operated the winch and allowed the carriage to gradually roll off the trailer.
Around 70 seconds later, the winch operator heard the chain drop and the carriage rolled away towards the level crossing, with no brakes or no mean of stopping it.
The carriage ran for more than 30 seconds passing through trailing points (which may have slowed it down) and onto the running line where it collided with the level crossing gates, no one was injured, but a pedestrian crossed the crossing just eight seconds before the carriage collided with the level crossing gates.
The RAIB says that the accident happened because the rope was not connected to the Pacer carriage in a way that provided a secure means of attaching.
The Mid Norfolk Railway says that they had appointed S A Smith to carry out the move, which it has used for this type of work before.
In its report, the RAIB says that the SA Smith workers followed the documentation on how to unload rail vehicles, however, the documentation referred to attaching the rope to a rail vehicle draw hook, but the centre carriage involved in the incident had no draw hook, nor did it have an automatic coupler.
There was also no evidence that the driver had looked for more information from the Mid Norfolk Railway when he realised.
The driver was aware that the rail vehicle bodywork could be corroded, so he considered the best way was the semi-permanent drawbar.
Pacer units semi-permanent drawbars have a square hollow bar that sandwiches a support plate in the middle for the gangway. The driver decided to wrap the chain around the drawbar before attaching the hook to the support plate.
How the chain passed over the coupling is unknown, but then the weight of the carriage was on a single set screw for the support plate.
The single set screw failed and meant that the support plate separated from the flange and chain to fall.
The Mid Norfolk Railway said it would not have provided SA Smith with information or guidance on unloading, nor did they request any. The railway said it considered the haulier to be an expert in moving rail vehicles.
Health & Safety Executive guidance says that while contractors have their own legal duties, anyone engaging a contractor has an H&S responsibility for both the contractor themselves and anyone affected by the work they do.
The Mid Norfolk Railway says that it has suspended loading and unloading at the siding and proposed changes to trackwork will remove direct access to the running line.
You can view the full report by clicking here.
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