GovWire

R042024_240516_Kineton

PDF, 7.26 MB, 55 pages

This file may not be suitable for users of assistive technology.

Request an accessible format.

If you use assistive technology (such as a screen reader) and need a version of this document in a more accessible format, please email enquiries@raib.gov.uk. Please tell us what format you need. It will help us if you say what assistive technology you use.

Summary

At around 21:08 hrs on 25 May 2023, an empty wagon ran away from the Ministry of Defence (MOD) sidings located within Kineton munitions depot, Warwickshire. It travelled for about 1.5 miles (2.4 km) on a predominantly descending gradient before it came to rest as the track gradient reversed.

During the runaway, the wagon pushed through two sets of trailing hand points which were set in an opposing direction, broke through the gates at the exit to the sidings, passed over two farm crossings, and traversed a level crossing on a public road. The wagon came to rest a short distance beyond the public road level crossing. Nobody was injured during the incident.

The wagon was owned by DB Cargo and leased to Kuehne+Nagel (K+N), who was operating it on behalf of MOD.

The investigation found that the wagon ran away because it was stabled on a gradient, as a single wagon, with insufficient brake force to restrain it, and without a system to prevent it from leaving the sidings.

RAIB identified three underlying factors. The first was that MODs contractors did not have sufficient expertise and resources to properly manage the risk of rail operations at Kineton. The second was that MOD did not provide effective safety leadership to its contractors. The final underlying factor was that the level of oversight by safety regulators meant that the lack of safety leadership within MOD rail operations was not identified and addressed.

RAIB also observed that the facilities used by DB cargo staff to carry out safety-critical maintenance activities were not well suited for the task.

Recommendations

RAIB has made five recommendations. The first is that MOD should review current arrangements to make sure that rail operations run on its behalf are being managed safely. The second asks MOD to work with statutory regulators and consider their regulation strategy for defence operated railways. The third recommendation aims for K+N to ensure that rail operations provided as part of the MOD contract are being managed safely. The fourth and fifth recommendations are addressed to DB Cargo and ask it to review its maintenance procedures for this wagon type and to ensure wagon brake components are scheduled for replacement at the end of their designed life.

RAIB identified one learning point, reminding shunters not to rely on handbrake indicators as the sole source of information regarding the handbrakes status.

Notes to editors

1. The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.

2. RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.

3. For media enquiries, please call 01932 440015.

